Predictive Value of Breast Lesions of “Uncertain Malignant Potential” and “Suspicious for Malignancy” Determined by Needle Core Biopsy

BACKGROUND: The optimum management of patients whose needle core biopsy (NCB) results are of "uncertain malignant potential" (B3) or "suspicious for malignancy" (B4) is unclear. This study correlates B3 and B4 NCB findings with excision histology to determine associated rates of malignancy. METHODS: All NCBs categorized as B3 or B4 were identified from a series of 3729 NCBs. Results of biopsies were reported as normal/nondiagnostic (B1), benign (B2), uncertain malignant potential (B3), suspicious but not diagnostic of malignancy (B4), or malignant (B5) according to the B classification system. B3 lesions included atypical intraductal epithelial proliferations (AIEPs), lobular neoplasia, papillary lesions, radial scars, and potential phyllodes tumors. Histological concordance between NCB and excision specimen was analyzed. RESULTS: A total of 211 B3 lesions and 51 B4 lesions were identified during the study period. The open biopsy rate after a B3/B4 finding was 86% (n = 226). The overall rate of malignancy for B3 lesions after excision was 21%. The B3 lesion-specific rates of malignancy were 6% for radial scars, 14% for papillomas, 35% for AIEP, and 44% for lobular neoplasia. Of the patients with a B4 categorization, 90% (44 of 49) were diagnosed with carcinoma after surgery. Those that were "suspicious for ductal carcinoma-in-situ" and "suspicious for invasion" correlated accurately with excision findings in 81% and 89% of patients, respectively. CONCLUSIONS: Management of lesions in the B3 categorization must be tailored to the patient because the specific lesion types are associated with highly variable rates of malignancy. A repeat biopsy or a therapeutic wide local excision should be undertaken in lesions with a B4 NCB categorization because such lesions are associated with a particularly high risk of malignancy at excision.     

Can Breast Magnetic Resonance Imaging Prevent Biopsy or Change the Management of BI-RADS® Category 4 Breast Lesions?

The BI-RADS® category 4 includes suspicious breast lesions which requires biopsy. The aim of this study is to investigate the contribution of breast magnetic resonance imaging to the management of BI-RADS® category 4 breast lesions detected by mammography and∕or ultrasonography. Thirty-four lesions classified as BI-RADS® category 4A, 4B, or 4C by conventional methods were evaluated with magnetic resonance imaging. All lesions were coded by using the American College of Radiology BI-RADS® lexicon. Each lesion was verified with the result of pathology. Lesions were evaluated as BI-RADS® category 1 in 1 patient (2.9%), category 3 (20.6%) in 7 patients, category 4 in 25 patients (73.6%), and category 5 in 1 patient (2.9%) with breast magnetic resonance imaging. Only the BI-RADS® 4A lesion categories were changed by breast magnetic resonance imaging, and these lesions were pathologically diagnosed as benign. The negative predictive value of breast MRI for BI-RADS® category 4A lesions was calculated as 100%. In all BI-RADS® category 4 lesions, pathologically 4 lesions found to be high risk and 3 lesions found to be malignant. The sensitivity, specificity, positive predictive, and negative predictive value of breast magnetic resonance imaging in BI-RADS® category 4 lesions were calculated as 100, 29.6, 26.9, and 100%, respectively. The area under the ROC curve was calculated 0.648. Breast magnetic resonance imaging is promising to be used as a problem-solving modality in BI-RADS® category 4A breast lesions.     

Is there an Upgrading to Malignancy at Surgery of Mucocele‐Like Lesions Diagnosed on Percutaneous Breast Biopsy?

Management of pure mucocele‐like lesion (MLL) diagnosed on percutaneous breast biopsy (PBB) is controversial. To assess surgical upgrade rate and clinical outcome of pure MLL obtained as sole diagnosis on PBB. Patients diagnosed with a MLL as the most advanced lesion on PBB from April 1997 to December 2010 were reviewed for radiologic presentation, biopsy technique, and pathologic and clinical outcomes. Of the 21,340 image‐guided PBB performed during the study period, 50 women with 51 MLL (0.24%) were identified. Mean age was 53.1 ± 7.7 years. Radiologic findings were mostly microcalcifications (n = 47, 92.2%). Stereotactic PBB was performed for 49 lesions (96.1%). Surgery was performed shortly after biopsy in 35 women, with benign final pathology in 33, and upgrade to ductal carcinoma in situ (DCIS) in two patients (2/35, 5.7%). Mean follow‐up was 4.2 ± 2.5 years (3.7 ± 2.1 years for surgical patients; 5.9 ± 2.9 years for follow‐up only patients); three women were lost to follow‐up (3/50). Three invasive cancers (3/47, 6.4%) were diagnosed 1.2, 1.2, and 2.8 years after biopsy: two in surgical patients, and one in a follow‐up only patient. No cancer occurred at the same site as the original MLL. Pure MLL lesion of the breast is a rare entity and is mostly associated with a benign outcome. We observed an upgrade to DCIS slightly superior to 5%, but no invasive cancer. It is therefore unclear if these lesions should be excised or clinically and radiologically followed up when such lesions are found at PBB.     

Management of Papillary Lesions of the Breast: Can Larger Core Needle Biopsy Samples Identify Patients Who May Avoid Surgical Excision?

Background

The ability to distinguish benign from atypical/malignant papillary lesions on core needle biopsy is limited by the representative nature of the biopsy method, thus follow-up excision is usually recommended. We aimed to determine if larger samples of tissue obtained by core needle biopsy can more reliably predict the true benign nature of a papilloma.

Methods

We reviewed the pathology slides and medical records of 51 patients who were diagnosed with benign papillomas on core needle biopsy from 2000 to 2010, who subsequently underwent surgical excision. The characteristics of the core needle biopsy that were associated with retention of benign histology on excision were determined and analyzed.

Results

Atypical ductal hyperplasia and carcinoma were identified in 5.8 % (3/51) and 5.8 % (3/51) of papillary lesions, respectively, when excised. Patients whose lesions were diagnosed as benign on excision were significantly distinguished by the area (mm²) of tissue sampled by core needle biopsy (mean ± standard deviation (SD): 101.5 ± 106.5) compared with those with atypia or carcinoma on excision (mean ± SD: 41.7 ± 24.0, P = 0.003). All biopsies performed with 12-gauge or larger needles retained benign features on excision. Core needle biopsy tissue samples consisting of ≥7 cores, or measuring >96 mm² in aggregate, had a negative predictive value for atypia/malignancy of 100 %.

Conclusions

Larger tissue samples significantly improved the predictive value of benign histology on core needle biopsy. A papilloma sampled by a 12-gauge or larger needle, ≥7 cores, or >96 mm² retained its benign features upon excision.     

Breast Lesion Excision Sample (BLES Biopsy) Combining Stereotactic Biopsy and Radiofrequency: Is it a Safe and Accurate Procedure in Case of BIRADS 4 and 5 Breast Lesions?

The aim of this study was to evaluate the accuracy and safety of breast lesion excision system (BLES) procedure with an Intact system device, under stereotactic and ultrasound guidance. Retrospective data review of 32 breast lesions BI‐RADS 4 or 5 underwent Intact procedures, from March 2010 to January 2012. Underestimation rates of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were evaluated; percentage of complete radiologic and histologic removal of the breast lesion were analyzed, as were the complications due to procedure. Complete radiologic excision of the target lesion was achieved in all masses and 58.6% of calcifications. Lesion size was less than 11 mm (mean size 5.6 mm). Underestimation of ADH and DCIS was 0% and 10%, respectively. Low complication rate was noted: only one hematoma. BLES appears an accurate and safe biopsy system for sampling nonpalpable breast lesions, especially in case of microcalcifications clusters categorized as BI‐RADS 4 and 5.     

Is Sentinel Node Biopsy of the Internal Mammary Lymph Nodes Relevant in the Management of Breast Cancer?

The aim of this study was to review the outcomes of a series of breast cancer patients who underwent sentinel node biopsy inclusive of lymphoscintigraphy, and to assess the incidence of internal mammary node (IMN) metastatic positivity at exploration and whether these findings influenced treatment. Between April 2001 and December 2012, 581 breast cancer patients at Princess Alexandra Hospital underwent preoperative lymphoscintigraphy in the course of the performance of sentinel node biopsy. Analysis was performed of those patients who demonstrated radio‐isotope uptake to the IMN chain, and who had sentinel node biopsy of the IMN's and were found to have metastatic involvement. Assessment was made to determine whether the finding of IMN metastases changed the adjuvant systemic management of these patients, and to review complication rates. 95 of 581 (16.4%) patients with preoperative breast lymphoscintigraphy had lymphatic mapping to the IMN chain. 51 (54%) of these patients had IMN chain surgically explored and IMN nodes were found in 35 of these patients (success rate of 69%). Of these, three patients (3/35 = 8.6%) had metastatic involvement of the IMN sentinel node group. All three IMN positive patients received adjuvant breast radiotherapy, chemotherapy, and hormonal therapy. In four patients (7.8%) IMN surgical exploration was complicated by pneumothorax. Only a small proportion of breast cancer patients were found to have metastasic involvement of the IMN chain and which did not significantly change their adjuvant therapy management. These findings suggest that the benefits of exploration of the IMN chain in breast cancer patients are limited and may be outweighed by the risk of complications.     

Surgical Management of Cephalic Arch Occlusive Lesions: Are There Predictors for Outcomes?

Cephalic arch lesions are common cause for dysfunction of brachiocephalic arteriovenous fistulas. For lesions resistant or not amenable to endovascular interventions, we used a term “cephalic arch occlusive lesions” (CAO) that included cephalic arch total occlusion, frequently recurrent stenosis (requiring angioplasty in <3‐month intervals), high‐grade elastic stenosis (residual stenosis >50% after angioplasty), or other lesions not amenable to endovascular interventions. Herein, we report 40 patients who underwent surgical revisions for total occlusions (17/40), frequently recurrent stenosis (17/40), high‐grade elastic stenosis (5/40), and zigzag stenosis (1/40). The revisions included cephalic transposition and venovenostomy (CTV = 37/40), basilic transposition and venovenostomy (1/40), stenotic segment resection (1/40), and cephalic‐jugular vein bypass graft (1/40). At 12‐month post‐CTV, the primary patency of the transposed cephalic vein, the fistula assisted primary and secondary patency rates were 25%, 82% and 97%, respectively. Notably, pre‐CTV angioplasty of the proximal cephalic vein was the only significant predictor for the low primary patency rate (hazard ratio 4.5, p = 0.002). Accordingly, the primary patency rates were 12% and 58% in patients with and without pre‐CTV angioplasty, respectively. In summary, surgical interventions are effective in salvaging fistulas complicated with CAO. Importantly, pre‐CTV angioplasty of the proximal cephalic vein might adversely affect the outcome of CTV.     

Which Eligible Breast Conservation Patients Choose Mastectomy in the Setting of Newly Diagnosed Breast Cancer?

Purpose  

Breast conserving therapy (BCT) and mastectomy offer equivalent survival for women with newly diagnosed breast cancer (BrCa). Despite this, many women eligible for BCT elect mastectomy. Herein, we identify factors associated with choosing ipsilateral mastectomy instead of BCT when mastectomy is not required.     

Fibroepithelial Lesions (FELs) of the Breast: Is Routine Excision Always Necessary?

World Journal of Surgery - When needle core biopsies (NCBs) of the breast reveal fibroepithelial lesions (FELs), excision is often performed to rule out a phyllodes tumor (PT), despite low...     

Percutaneous Needle Biopsy for Breast Diagnosis: How Do Surgeons Decide?

Background  Despite the advent of guidelines recommending core needle biopsy (CNB) for diagnosis of breast abnormalities, it is underused in some jurisdictions. We sought to determine those factors influencing surgeons’ choices of breast biopsy techniques. Methods  We surveyed 385 general surgeons in Ontario to first determine factors influencing the choice of fine-needle aspiration biopsy (FNAB), CNB, both or neither for diagnosis of breast abnormalities in six clinical scenarios with varying risk of malignancy. Second, respondents were asked to rate 15 patient, organizational, and system factors for their impact on choice of biopsy technique. Third, surgeons were asked to describe their three greatest barriers to provision of cancer care. Results  Response rate was 44%, and 126 provided answers to the survey questions. When there was a high risk of malignancy, CNB and/or FNAB were favored over surgical biopsy (83% to 97% compared with 41% for presumed benign lesions), and CNB was preferred for percutaneous biopsy over FNAB (58% to 79% compared with 1% to 18%). Patient and clinical factors (46% FNAB, 42% CNB), patient preference for biopsy technique (34%, 31%), and delayed access to CNB, rather than lack of equipment (11% FNAB, 8% CNB) or expertise for CNB or FNAB (15%, 12%), had the greatest reported impact on choice of biopsy technique. Conclusions  Surgeon preference for CNB is higher than actual use. Further research is needed to establish whether or how CNB use could be improved by support for shared decision making or facilitating access.     

Benign Papillomas of the Breast Diagnosed on Large‐Gauge Vacuum Biopsy compared with 14 Gauge Core Needle Biopsy – Do they require surgical excision?

To evaluate whether biopsy with vacuum‐assisted biopsy (VAB) devices improves histologic underestimation rates of benign papillomas when compared to smaller bore core needle biopsy (CNB) devices. Patients with biopsy‐proven benign papillomas with surgical resection or minimum 12 months follow‐up were selected. Two breast pathologists reviewed all pathology slides of percutaneous and excisional biopsy specimens. Histologic underestimation rates for lesions biopsied with 10–12 Gauge (G) VAB were compared to those with 14G CNB. A total of 107 benign papillomas in 107 patients from two centers were included. There were 60 patients (mean age 57 years, SD 10.3 years) diagnosed with VAB and 47 patients (mean age 57.6 years, SD 11.3 years) with 14G CNB who underwent surgical excision or imaging follow‐up. The upgrade rate to ductal carcinoma in situ or invasive carcinoma was 1.6% (1/60) with VAB and 8.5% (4/47) with 14G. Upgrade to atypia was 3.3% (2/60) after VAB and 10.6% (5/47) with CNB. The total underestimation rates were 5% (3/60) with VAB and 19.1% (9/47) with CNB. The odds of an upgrade to malignancy was 5.5 times higher with a 14G needle than VAB (95% CI: 0.592–50.853, p = 0.17). We observed a lower but not statistically significant upgrade rate to malignancy and atypia with the use of the 10–12 G VAB as compared with 14G CNB. When a papilloma without atypia is diagnosed with vacuum biopsy there is a high likelihood that it is benign; however, if surgical excision is not performed, long‐term follow‐up is still required.