Percutaneous core needle biopsy of radial scars of the breast: when is excision necessary?

OBJECTIVE:. This study was conducted to evaluate the outcome of cases of radial scar diagnosed by percutaneous core needle biopsy. MATERIALS AND METHODS: Of 198 nonpalpable lesions diagnosed with radial scars found at core needle biopsy, 157 lesions constituting the study group had undergone surgical excision (n = 102) or mammographic surveillance after biopsy for at least 24 months (median, 38 months; n = 55). Mammographic lesion type, lesion size, biopsy guidance method, biopsy device, number of specimens per lesion, and presence of atypical hyperplasia at percutaneous biopsy were retrospectively analyzed. Results were compared with histologic findings at surgery or mammographic findings during surveillance. RESULTS:. Carcinoma was found at excision in 28% (8/29) of lesions with associated atypical hyperplasia at percutaneous biopsy and 4% (5/128) of lesions without associated atypia (p < 0.0001). In the latter group, carcinoma was found at excision in 3% (2/60) of masses, 8% (3/40) of architectural distortions, and 0% (0/28) of microcalcification lesions. Malignancy was missed in 9% (5/58) of lesions biopsied with a spring-loaded device and in 0% (0/70) of lesions biopsied with a directional vacuum-assisted device (p = 0.01); and in 8% (5/60) of lesions sampled with less than 12 specimens per lesion and 0% (0/68) sampled with 12 or more specimens (p = 0.015). Lesion type, maximal lesion diameter, and type of imaging guidance (stereotactic or sonographic) were not significant factors in determining the presence of malignancy. CONCLUSION:. Diagnosis of radial scar based on core needle biopsy is likely to be reliable when there is no associated atypical hyperplasia at percutaneous biopsy, when the biopsy includes at least 12 specimens, and when mammographic findings are reconciled with histologic findings. When the lesion diagnosed by core needle biopsy as radial scar does not meet these criteria, excisional biopsy is indicated.     

Targeted MRI-guided prostate biopsy: are two biopsy cores per MRI-lesion required?

Purpose

This study evaluates the feasibility of performing less than two core biopsies per MRI-lesion when performing targeted MR-guided in-bore prostate biopsy.

Methods

Retrospectively evaluated were 1545 biopsy cores of 774 intraprostatic lesions (two cores per lesion) in 290 patients (66?±?7.8 years; median PSA 8.2 ng/ml) regarding prostate cancer (PCa) detection, Gleason score, and tumor infiltration of the first (FBC) compared to the second biopsy core (SBC). Biopsies were acquired under in-bore MR-guidance.

Results

For the biopsy cores, 491 were PCa positive, 239 of 774 (31 %) were FBC and 252 of 771 (33 %) were SBC (p?=?0.4). Patient PCa detection rate based on the FBC vs. SBC were 46 % vs. 48 % (p?=?0.6). For clinically significant PCa (Gleason score ≥4?+?3?=?7) the detection rate was 18 % for both, FBC and SBC (p?=?0.9). Six hundred and eighty-seven SBC (89 %) showed no histologic difference. On the lesion level, 40 SBC detected PCa with negative FBC (7.5 %). Twenty SBC showed a Gleason upgrade from 3?+?3?=?6 to ≥3?+?4?=?7 (2.6 %) and 4 to ≥4?+?3?=?7 (0.5 %).

Conclusion

The benefit of a second targeted biopsy core per suspicious MRI-lesion is likely minor, especially regarding PCa detection rate and significant Gleason upgrading. Therefore, a further reduction of biopsy cores is reasonable when performing a targeted MR-guided in-bore prostate biopsy.

Key Points

? Higher PI-RADS overall score (IV-V) correlated well with PCa detection rate ? In more than 80 % SBC was concordant regarding overall PCa detection ? In almost 90 % there was no Gleason upgrading by the SBC ? Only 2/54 (3.7 %) csPCa was missed when the SBC was omitted ? For IB-GB a further reduction of biopsy cores is reasonable

     

US-guided core-needle biopsy of the breast: how many specimens are necessary?

PURPOSE: To analyze the diagnostic yield for each specimen obtained at 14-gauge ultrasonography (US)-guided breast biopsy and compare these findings with mass, procedural, and specimen characteristics that could affect yield. MATERIALS AND METHODS: Seventy-three consecutive biopsies of breast masses were performed by using a 14-gauge handheld biopsy device. Each specimen was graded for whether it was nonfragmented or fragmented and for whether it sank or floated, and each pass was graded for whether or not the needle passed through the lesion. Each specimen was mounted on a separate slide. A pathologist who was unaware of the final diagnoses reviewed the slides in random order. A diagnosis was determined for each specimen whenever possible, and diagnostic yield was calculated as a function of number of passes. The Fisher exact test was used to compare yield for different specimen characteristics. RESULTS: Fourteen (19%) lesions were malignant and 59 (81%) were benign. Cells indicating the final diagnosis were contained in 249 (75%) of 334 specimens. Cells indicating the diagnosis were contained in the first specimen in 51 (70%) lesions, in the second specimen in 67 (92%), in the third specimen in 70 (96%), and in the fourth specimen in 73 (100%). Of the 14 malignancies, 13 (93%) were diagnosed with cells contained in the first or second specimen; one cancer (ductal carcinoma in situ) was diagnosed with cells contained in the fourth specimen. Specimens that were nonfragmented (P <.001) and sank (P <.001) showed correlation with being diagnostic, but needle visualization within the lesion did not. CONCLUSION: A minimum of four specimens, preferably those that are nonfragmented and that sink, should be obtained with 14-gauge US-guided breast biopsy.     

Learning curve for stereotactic breast biopsy: how many cases are enough?

OBJECTIVE: The objective of this study was to evaluate the learning curve for stereotactic breast biopsy. MATERIALS AND METHODS: Retrospective review was performed of 923 consecutive lesions that underwent stereotactic breast biopsy performed by one of six radiologists. Four hundred fourteen lesions had 14-gauge automated core biopsy, and 509 subsequent lesions had vacuum-assisted biopsy (14-gauge in 163 and 11-gauge in 346). Medical records were reviewed to determine the technical success rate and false-negative rate as a function of operator experience. RESULTS: For 14-gauge automated core biopsy, a significantly lower technical success rate was seen for the first five cases of each radiologist than for subsequent cases (25/30 = 83.3% versus 366/384 = 95.3%, p < 0.02) and for the first 20 cases than for subsequent cases (90/100 = 90% versus 284/296 = 95.9%, p < 0.05). For 11-gauge vacuum-assisted biopsy, a significantly lower technical success rate was seen for the first five cases than for subsequent cases (17/20 = 85.0% versus 310/322 = 96.3%, p < 0.05) and for the first 15 cases than for subsequent cases (54/60 = 90.0% versus 273/283 = 96.5%, p = 0.03). The false-negative rate was higher for the first 15 cases compared with subsequent cases both for stereotactic 14-gauge automated core biopsy (4/31 = 12.9% versus 3/115 = 2.6%, p < 0.04) and for stereotactic 11-gauge vacuum-assisted biopsy (2/27 = 7.4% versus 0/85 = 0%, p < 0.06). CONCLUSION: A learning curve exists for stereotactic breast biopsy. Significantly higher technical success rates and lower false-negative rates were observed after the first five to 20 cases for 14-gauge automated core biopsy and after the first five to 15 cases for 11-gauge vacuum-assisted biopsy. Even after a radiologist has experience with stereotactic biopsy, changes in equipment may result in a new learning curve.     

Can galactography-guided stereotactic, 11-gauge, vacuum-assisted breast biopsy of intraductal lesions serve as an alternative to surgical biopsy?

The purpose of this study was to determine the value of galactography-guided, stereotactic, vacuum-assisted breast biopsy (VABB) for the assessment of intraductal breast lesions and its potential as a therapeutic tool that could eliminate the need for surgical excision. Eighteen patients (median age 64 years, range 37–80) with nipple discharge and galactography-verified intraductal lesions underwent galactography-guided, stereotactic, 11-gauge VABB followed by surgery. Histopathology findings from VABB and subsequent surgery were compared. Underestimation and false-negative rates were assessed. After VABB, histopathology revealed invasive ductal carcinoma (IDC) in three (17%), ductal carcinoma in situ (DCIS) in six (33%), high-risk lesions in six (33%) and benign lesions in three (17%) cases. After surgical biopsy, histopathology confirmed the previously established diagnosis in 11 lesions (61%). The underestimation rate for high-risk lesions and DCIS was 50% (6/12). The false-negative rate was 7% (1/14). Histopathology examination after surgery showed that not a single lesion had been completely removed at VABB. Galactography-guided VABB is a feasible diagnostic tool. However, its value as a therapeutic procedure is limited because of the high number of underestimated and missed lesions and because of the histopathological detection of lesions’ remnants in every case. Surgical excision should be the therapeutic gold standard in cases of pathological nipple discharge and galactography abnormalities.     

Add-on device for stereotactic core-needle breast biopsy: how many biopsy specimens are needed for a reliable diagnosis?

PURPOSE: To prospectively determine whether there is a minimum number of cores required for histopathologic diagnosis of mammographically detected nonpalpable breast lesions with an add-on 14-gauge stereotactic core-needle biopsy device. MATERIALS AND METHODS: The study was approved by the ethics committee of the hospital; informed consent was obtained. Biopsy was performed in 197 patients with 205 lesions (97 masses, 108 microcalcifications). The first sample (from the center) was collected in container A; second and third samples (2 mm from center), in container B; and additional samples, in container C. Malignancies, atypical ductal hyperplasia (ADH), and radial scars were excised. Benign lesions were followed up mammographically (mean, 24 months). Strict sensitivity and working sensitivity were calculated separately. Stereotactic biopsy with diagnosis of a nonmalignant lesion that, after surgery, proved to be malignant was considered false-negative when strict sensitivity was calculated. Stereotactic biopsy with diagnosis of ADH or radial scar was considered true-positive if the findings at surgery corresponded to the results at biopsy or indicated malignancy and was considered false-positive if the findings at surgery were benign when working sensitivity was calculated. Sensitivity, specificity, and overall accuracy of stereotactic biopsy were determined for masses and microcalcifications in all three containers by using surgical samples and findings at mammographic follow-up as reference. At chi2 analysis, P < .05 was considered to indicate significant difference. RESULTS: Strict sensitivity of the first sample was 77% (66 of 86) (90% [35 of 39] for masses, 66% [31 of 47] for microcalcifications). Results of the first sample were false-negative significantly more often in microcalcifications (n = 16) than in masses (n = 4) (P = .010). Combined results of containers A and B (ie, three samples) yielded higher strict sensitivity than those with first sample alone (95% [37 of 39] for masses [P = .196], 91% [43 of 47] for microcalcifications [P < .001]). With multiple samples, strict and working sensitivity were both 100% (39 of 39) for masses and 91% (43 of 47) and 98% (46 of 47), respectively, for microcalcifications. Four false-negative diagnoses (ADH, three cases; lesion with discordant mammographic and stereotactic biopsy findings, one case) were microcalcifications. CONCLUSION: More than three samples are needed (a minimum number was not determined) for a histologic diagnosis of a mass lesion by using an add-on stereotactic biopsy device.     

Palpable breast masses: is there a role for percutaneous imaging-guided core biopsy?

OBJECTIVE: The purpose of this study was to evaluate percutaneous imaging-guided core biopsy in the assessment of selected palpable breast masses. MATERIALS AND METHODS: Of 1388 consecutive breast lesions that had percutaneous imaging-guided core biopsy, 155 (11%) were palpable. Palpable masses referred for percutaneous imaging-guided core biopsy included lesions that were small, deep, mobile, vaguely palpable, or multiple. Biopsy guidance was sonography in 140 lesions (90%) and stereotaxis in 15 (10%). Surgical correlation or minimum of 2 years follow-up is available in 115 palpable masses in 107 women. Medical records, imaging studies, and histologic findings were reviewed. RESULTS: Of 115 palpable breast masses, 98 (85%) were referred by surgeons to the radiology department for percutaneous imaging-guided core biopsy and 88 (77%) had percutaneous imaging-guided core biopsy on the day of initial evaluation at our institution. Percutaneous imaging-guided core biopsy spared additional diagnostic tissue sampling in 79 (74%) of 107 women, including 57 women with carcinoma and 22 women with benign findings. Percutaneous imaging-guided core biopsy did not spare additional tissue sampling in 28 women (26%), including 15 women in whom surgical biopsy was recommended on the basis of percutaneous biopsy findings and 13 women with benign (n = 7) or malignant (n = 6) percutaneous biopsy findings who chose to undergo diagnostic surgical biopsy. CONCLUSION: Percutaneous imaging-guided core biopsy is useful in the evaluation of palpable breast masses that are small, deep, mobile, vaguely palpable, or multiple. In this study, percutaneous imaging-guided core biopsy spared additional diagnostic tissue sampling in 74% women with palpable breast masses.     

High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: can underestimation be predicted?

Objectives

To evaluate the frequency of diagnosis of high-risk lesions at MRI-guided vacuum-assisted breast biopsy (MRgVABB) and to determine whether underestimation may be predicted.

Methods

Retrospective review of the medical records of 161 patients who underwent MRgVABB was performed. The underestimation rate was defined as an upgrade of a high-risk lesion at MRgVABB to malignancy at surgery. Clinical data, MRI features of the biopsied lesions, and histological diagnosis of cases with and those without underestimation were compared.

Results

Of 161 MRgVABB, histology revealed 31 (19%) high-risk lesions. Of 26 excised high-risk lesions, 13 (50%) were upgraded to malignancy. The underestimation rates of lobular neoplasia, atypical apocrine metaplasia, atypical ductal hyperplasia, and flat epithelial atypia were 50% (4/8), 100% (5/5), 50% (3/6) and 50% (1/2) respectively. There was no underestimation in the cases of benign papilloma without atypia (0/3), and radial scar (0/2). No statistically significant differences (p?>?0.1) between the cases with and those without underestimation were seen in patient age, indications for breast MRI, size of lesion on MRI, morphological and kinetic features of biopsied lesions.

Conclusions

Imaging and clinical features cannot be used reliably to predict underestimation at MRgVABB. All high-risk lesions diagnosed at MRgVABB require surgical excision.     

Probably benign breast masses at US: is follow-up an acceptable alternative to biopsy?

PURPOSE: To retrospectively determine whether nonpalpable solid breast masses that were partially or completely obscured at mammography and diagnosed as probably benign only at ultrasonography (US) can be safely managed with follow-up. MATERIALS AND METHODS: The local ethics committee approved this study; informed consent was not required. In 409 women, 448 nonpalpable solid masses were identified and classified as probably benign at US; at mammography these masses were either partially or completely obscured by dense fibroglandular tissue. Of the 448 masses, 445 were followed up, while biopsy was performed after initial imaging in the remaining three. False-negative rates, negative predictive values (NPVs), and exact 95% confidence intervals (CIs) were calculated. RESULTS: Of the 445 masses, 442 remained stable at follow-up (range, 2-5 years; mean, 3.3 years). Two masses increased (fibroadenomas at biopsy). One mass became palpable, and cancer was diagnosed at biopsy. The three masses in which initial biopsy was performed were fibroadenomas. The false-negative rate was 0.2% (one of 448; NPV, 99.8%; 95%CI: 0.0%, 1.23%). CONCLUSION: Follow-up US appears to be an acceptable alternative to biopsy for solid masses with benign morphologic features seen at US owing to the extremely high NPV (99.8%).     

Post-lumpectomy breast calcifications: Can original tumor features assist in determining need for biopsy?

ObjectiveThe objective of our study was to determine whether, in the digital era, imaging features of a primary breast tumor can be used to influence the decision to biopsy ipsilateral breast calcifications that occur following surgery in women treated with breast conservation surgery (BCS).Materials and methodsWe retrospectively identified women treated with BCS who subsequently developed suspicious calcifications in the treated breast (BI-RADS 4 or 5) from January 2012 – December 2018. Only cases with histopathological diagnosis by stereotactic or surgical biopsy were included. Pathology reports were reviewed, and biopsy results were considered malignant if invasive carcinoma or ductal carcinoma in situ (DCIS) was found. All other results were considered benign.Fisher's exact test was done comparing frequencies of malignancy between those patients whose original tumor had calcifications versus those whose original tumors were not calcified.ResultsOf 90 women with suspicious calcifications on a post-BCS mammogram, 65 (72.2%) were biopsy proven benign and 25 (27.8%) were malignant. The original tumor presented without calcifications in 39 patients (43%), and 51 (57%) had calcifications with or without associated mass, focal asymmetry, or architectural distortion. New calcifications were less likely to be malignant if the original tumor presented without calcifications (5/39; 12.8%) as compared to original tumors with calcifications (20/51; 38.5%) [p-value < 0.05].ConclusionNew calcifications after BCS are significantly less likely to be malignant if the original tumor presented without calcifications. However, with a PPV of 12.8%, even calcifications in a patient with a non-calcified primary tumor require biopsy.     

Can unenhanced breast MRI be used to decrease negative biopsy rates?

PURPOSE

We aimed to determine whether low-risk breast masses can be effectively managed with unenhanced magnetic resonance imaging (MRI) combining T2-weighted sequences with diffusion-weighted imaging (DWI) instead of immediate biopsy to decrease negative biopsy rates.

METHODS

After institutional review board and patient approvals, 141 consecutive women with 156 low-risk breast masses, who underwent unenhanced MRI and later on received a final diagnosis, were included in the study. There were 72 BI-RADS 3 masses in women with relative risk factors and 84 BI-RADS 4A masses, all referred for biopsy. Apparent diffusion coefficient (ADC) cutoff was 0.90×10-3 mm2/s. According to ADC values and T2-weighted imaging characteristics, masses were classified as either malignant or benign. Unenhanced MRI results were compared with final diagnoses obtained by histopathology or imaging surveillance, and diagnostic values were calculated.

RESULTS

Of 156 masses, 112 underwent biopsy. Four malignancies were diagnosed, three of which having ADC values lower than the cutoff. In women who rejected the biopsy, masses were stable during a follow-up of at least two years (n=44). MRI revealed 91% specificity and 99% negative predictive value (NPV) for detection of breast cancer.

CONCLUSION

Combination of T2-weighted imaging with DWI is a feasible method to further characterize breast masses with a low probability of malignancy. With the use of unenhanced MRI instead of immediate biopsy, it might be possible to decrease negative biopsy rates of low-risk breast masses.The Breast Imaging Reporting and Data Systems (BI-RADS) lexicon (1) of American College of Radiology (ACR) provides an efficient and standardized assessment and management of breast lesions. It also stratifies breast cancer risk for a given lesion by classifying them into categories 1 through 5 according to the degree of suspicion.According to this system, solid masses with a circumscribed margin, oval shape (including those with two or three gentle lobulations) and parallel orientation on ultrasonography (US) exam are classified as BI-RADS 3. These types of masses are commonly seen at diagnostic and screening examinations. In this category malignancy is highly unlikely (less than 2%) and a short interval follow-up is recommended (1). However, up to one-third of such masses undergo biopsy mainly because of radiologist, referring clinician, or patient concern about the substantial risk of malignancy (2–4). Many BI-RADS 3 masses are traditionally referred for biopsy if they are palpable, large in size, patient is of advanced age or has a positive family history for breast cancer.The BI-RADS 4 assessment is reserved for findings that do not have the classic appearance of malignancy but are sufficiently suspicious to justify a recommendation for biopsy. This category is largely indeterminate and highly variable in outcome. Breast lesions in this category carry 2% to 95% risk for malignancy (1). Thus, almost all recommendations for breast biopsies come from assessments made using this category. According to BI-RADS classification; category 4 is subgrouped as 4A, 4B, and 4C to better inform the clinicians, pathologists, and patients of the degree of concern. However, the criteria for distinguishing among these subcategories have not been well delineated. BI-RADS 4A designates lesions with a low suspicion for malignancy. In this group, a benign pathologic diagnosis is expected and considered concordant (1). Studies of several institutions by the use of their internal criteria revealed positive predictive value (PPV) of 7%–9% for 4A lesions, and more than 50% of the suspicious lesions fall into this category. On the other hand, BI-RADS 4B and 4C designate lesions with moderate and high suspicion for malignancy and PPV in these categories were reported to be 19%–38% and 57%–82%, respectively (5–7).Approximately 70%–80% of breast biopsies result in benign diagnosis (8, 9). Although the risk of malignancy is low, many BI-RADS 3 masses and all subcategory 4A masses are referred for biopsy. These two groups constitute the main source of negative biopsies which load unnecessary fear, anxiety, discomfort, pain, and financial cost to these patients.Breast magnetic resonance imaging (MRI) is a well-established advanced technique for evaluation of the breast masses. Dynamic contrast-enhanced (DCE) imaging has high sensitivity, and it is the most proposed breast MRI method. However, this method is time consuming, needs contrast injection, has moderate specificity, and is relatively difficult to evaluate (10–12). DCE MRI evaluation of all low-risk lesions recommended for biopsy would not be cost effective. On the other hand, diffusion weighted imaging (DWI) is a newly proposed and highly effective MRI technique used for characterization of breast lesions, especially of masses, by measuring the random motion of free water protons in tissues. DWI is easy to evaluate, does not require contrast injection, has short imaging time and shows higher specificity (reported to be 84% in a meta-analysis) than DCE imaging (13).The purpose of this study was to investigate the value of unenhanced MRI combining T2-weighted sequences with DWI for further characterization of breast masses having a low probability of being malignant (BI-RADS 3 and 4A). We hypothesized that unnecessary breast biopsies performed for benign masses might be decreased by evaluating these masses with unenhanced MRI.     

En bloc excision of nonpalpable breast lesions using the advanced breast biopsy instrumentation system: an alternative to needle guided surgery?

This study was prospectively conducted to evaluate the clinical potential of the advanced breast biopsy instrumentation (ABBI) system as an alternative to needle localization and open surgery in the management of nonpalpable breast lesions (NPBL). One hundred and eighty-six consecutive patients were referred for management of NPBL. Thirty-six underwent an ABBI procedure, offered as a first step before possible surgery for lesions which would in any case have required complete excision. The 18 patients with a malignant ABBI biopsy underwent re-excision of the biopsy site and axillary dissection was carried out in cases of infiltrating carcinoma. The other 150 patients underwent image-guided needle biopsy. Following these procedures, 60/150 (40 %) patients underwent needle-guided surgery. Finally, 96/186 (51 %) patients required complete excision. A total of 43 benign lesions and 53 carcinomas were confirmed. Thirty-six out of 96 (38 %) excisions were obtained with the ABBI system; 17/43 (40 %) benign lesions and 11/53 (21 %) carcinomas were completely removed with the ABBI system. Out of 9 malignant specimens with a pathological size less than 10 mm, 5/9 (55 %) had tumor-free margins and in 8/9 (89 %) no residual disease was found at re-excision. The preliminary results of this study suggest that, in selected cases, en bloc excision using the ABBI procedure could be an alternative to conventional surgery. Received: 4 September 2000 Accepted: 27 September 2000