Stereotactic needle breast biopsy: a review of current status and practice

The early detection of breast cancer is a concern to women and their physicians. Although screening mammography can identify early breast lesions, many are small and non-palpable. In the past, open excisional biopsy often was required to establish the diagnosis. Recently, stereotactic breast biopsy, a minimally invasive technique, has permitted tissue diagnosis of small lesions without open surgery, with results comparable to those obtainable with excisional biopsy. We reviewed this technique, its application in identifying small breast lesions, and in diagnosing breast cancer in its early stages.     

AGO Recommendations for the Surgical Therapy of Breast Cancer: Update 2022

The recommendations of the AGO Breast Committee on the surgical therapy of breast cancer were last updated in March 2022 (www.ago-online.de). Since surgical therapy is one of several partial steps in the treatment of breast cancer, extensive diagnostic and oncological expertise of a breast surgeon and good interdisciplinary cooperation with diagnostic radiologists is of great importance. The most important changes concern localization techniques, resection margins, axillary management in the neoadjuvant setting and the evaluation of the meshes in reconstructive surgery. Based on meta-analyses of randomized studies, the level of recommendation of an intraoperative breast ultrasound for the localization of non-palpable lesions was elevated to “++”. Thus, the technique is considered to be equivalent to wire localization, provided that it is a lesion which can be well represented by sonography, the surgeon has extensive experience in breast ultrasound and has access to a suitable ultrasound device during the operation. In invasive breast cancer, the aim is to reach negative resection margins (“no tumor on ink”), regardless of whether an extensive intraductal component is present or not. Oncoplastic operations can also replace a mastectomy in selected cases due to the large number of existing techniques, and are equivalent to segmental resection in terms of oncological safety at comparable rates of complications. Sentinel node excision is recommended for patients with cN0 status receiving neoadjuvant chemotherapy after completion of chemotherapy. Minimally invasive biopsy is recommended for initially suspect lymph nodes. After neoadjuvant chemotherapy, patients with initially 1 – 3 suspicious lymph nodes and a good response (ycN0) can receive the targeted axillary dissection and the axillary dissection as equivalent options.Key words: breast cancer, breast surgery, surgical therapy, guidelines, neoadjuvant chemotherapy     

Current role of liquid biopsy in metastatic breast cancer and future perspectives

The possibility of tumor dissemination via the blood system has been known for many years. Circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA) are detectable in the peripheral blood of patients with early as well as metastatic breast cancer. The prognostic relevance of these biomarkers has already been described. Repeated blood sampling along the course of disease enables CTCs and ctDNA to be monitored in terms of a regular “liquid biopsy”. Combined with an additional molecular analysis, this might be helpful in gaining information about tumor characteristics, tumor heterogeneity, and possible therapy resistance based on these factors, without the necessity of an invasive core biopsy. The assessment of molecular attributes may be indispensable for obtaining an optimized and personalized therapy aimed at extended survival and/or improved quality of life. This review summarizes current knowledge and describes possible future perspectives for the treatment of metastasized breast cancer.     

Diagnostik des Mammakarzinoms

Suspicious findings detected during screening procedures are assessed by a clinical examination and additional imaging usually including sonography and a percutaneous biopsy has to be performed to histologically confirm or exclude a malignancy. This algorithm, as determined by the national guidelines on early detection, is adhered to in normal routine care. Clinical examination and mammography compliment each other. A malignancy can only be excluded by mammography in cases of complete parenchymal involution which is by no means possible with ultrasound or magnetic resonance imaging (MRI). The triple test is considered to be the gold standard of breast cancer diagnosis combining imaging with percutaneous biopsy. To detect ductal carcinoma in situ (DCIS) mammography and MRI seem to be complimentary methods, whereas the sensitivity of sonography is limited in such cases. Ultrasound examination is, however, the most important method complementing mammography in the detection and diagnosis of invasive malignancies. Histological assessment remains the reference standard and imaging-guided interventions are considered to be core methods of breast cancer diagnosis. Because every biopsy method has its own limitations determined by the morphology, strict radiological and histological correlation is mandatory.     

Techniken zur Markierung des Sentinellymphknotens beim Mammakarzinom

Lymphatic mapping in breast cancer treatment is important for histopathological tumor classification, evaluation of individual prognosis, and serves for local tumor control. Adjuvant therapeutic decisions should be based on it. Axillary dissection is still the so called “golden standard” in operative breast cancer treatment. But minimal invasive selective lymphadenectomy is an attractive approach to reduce axillary morbidity. The lymphatic flow is visualized by injection of radioactive tracer (Technetium) or dye (Patentblau V). The first lymph node on a direct drainage pathway from the primary tumor is identified as sentinel lymph node. The sentinel lymph node biopsy has to be implemented for early breast cancer treatment under terms of quality assurance and interdisciplinary involvement of nuclear physicians, surgeons, pathologists and radiologists. As a new experimental approach Technetium labeled specific antibodies are used as tracer for immunoscintigraphy. Another new technique uses the magnetic resonance imaging system. These novel approaches for lymphatic mapping needs further evaluation.     

Controversies in Sentinel Lymph Node Biopsy for Gynecologic Malignancies

ObjectiveSentinel lymph node (SLN) biopsy represents an evolution in the advancement of minimally invasive surgical techniques for gynecologic cancers. Prospective and retrospective studies have consistently shown its accuracy in the detection of lymph node metastases for endometrial and cervical cancers. However, consistent with any emerging surgical technique in the early phases of adoption, new questions have arisen regarding its application and impact. This paper served as a scoping review to identify the key controversies that have arisen in the field of SLN biopsy for endometrial and cervical cancers.Data SourcesSeveral key controversies were identified, and PubMed, the Cochrane Library (cochranelibrary.com) advanced search function, and the National Comprehensive Cancer Network guidelines were searched for supporting evidence. These included search terms such as “the accuracy of SLN biopsy for high grade endometrial cancer or cervical cancers >2-cm,” “cost effectiveness of SLN biopsy for gynecologic cancers,” “clinical significance of low volume metastases in endometrial cancer,” “morbidity of SLN biopsy for endometrial and cervical cancer,” and “impact on cancer survival of SLN biopsy for endometrial and cervical cancer.”Methods of Study SelectionStudies were selected for review if they included significant numbers of patients, were level I evidence, or were prospective trials. Where this level of evidence failed to exist, seminal observational series that were published in high-quality journals were included.Tabulation, Integration, and ResultsSimilar studies were listed and subcategorized and cross-compared, excluding those that included repeated analyses of the same patient populations. The relevant clinical trials or observational studies were clustered and reviewed for each chosen controversy. Adequate evidence supports the accuracy of SLN biopsy in the staging of high-grade endometrial cancer and cervical cancer, and it seems to be a cost-effective strategy for invasive endometrial cancer. Conclusive evidence was lacking with respect to the oncologic outcomes related to SLN biopsy, the impact on patient morbidity, and whether clinicians should treat isolated tumor cells in SLNs with adjuvant therapy.ConclusionSLN biopsy is an accepted staging strategy for cervical and endometrial cancer surgery; however, controversies remain in how it can be applied with the most safety and efficacy. These ultimately need to be resolved with further clinical trials and observations of larger series of patients.     

Open surgical biopsy for nonpalpable breast lesions detected on screening mammography

The aim of this retrospective clinical study was the analysis of histologic findings of nonpalpable breast lesions managed by open surgical biopsy. A series of 630 women underwent 664 preoperative localizations of nonpalpable, mammographically detected breast lesions during the last 10-year period. Indications for biopsy were (1) clustered microcalcifications, (2) solid mass, and (3) radiologic parenchymal distortion. The lesions were localized preoperatively using hook-wire methods, and all biopsies were performed under general anesthesia. Histopathology revealed carcinoma in 172 (25.9%) cases; noninvasive in 114 (66.3%) cases and infiltrating in 58 (33.7%) cases. The highest malignancy rate was found in cases with microcalcifications (112 carcinomas out of 323 cases, 34.7%). Lymph node invasion was present in 25% of patients with invasive cancers. The hook-wire localization of nonpalpable breast lesions is a simple, accurate and safe method for detection of early breast cancers. Frozen section is feasible and accurate in the majority of these lesions, and therefore, diagnostic and therapeutic one-step surgical procedures could be performed.     

Sonographische Diagnostik bei abnorm invasiver Plazenta

Abnormally invasive placenta (AIP or “morbidly adherent placenta”) significantly contributes to maternal morbidity and mortality, potentially causing severe hemorrhage at delivery. Previous uterine surgery is the main risk factor. It may be speculated that with the rise in Caesarean delivery rates the incidence of AIP will also increase. Prenatal detection of AIP is mandatory to reduce the perinatal morbidity. Obstetrical ultrasound should be used as a screening tool for AIP. There are well known sonographic signs in B-mode, color Doppler and dynamic ultrasound that form the basis for prenatal detection. This review highlights these ultrasound markers and shows clinical examples.     

Suspicious axillary lymph nodes in patients with unremarkable imaging of the breast

Objective

The aim of this study was to evaluate the pathological findings and the method of tissue harvesting in those patients who have both suspicious axillary lymph nodes and normal imaging of the breast.

Study design

From January 2005 to June 2008 all female patients who underwent opportunistic screening mammography and ultrasound examination of the breast and the axilla, and who were found to have suspicious axillary lymph nodes seen on ultrasound examination, were retrospectively analysed. Tissue harvesting was done by fine needle aspiration, core needle biopsy, or open biopsy.

Results

Out of approximately 7500 screened patients, 51 were found to have suspicious axillary lymph nodes on ultrasound with unremarkable breast ultrasound and mammography. Histopathology and/or cytology of these lymph nodes showed 33 benign and 18 malignant results. Of the malignant results only 1 case was an occult invasive lobular breast carcinoma detected afterwards on breast magnetic resonance imaging. Eleven cases were non-Hodgkin lymphomas, 4 were malignant melanomas, and 2 were metastases from the lower genital tract. Diffuse cortical thickening and complete loss of echo texture were the only features on ultrasound predicting malignancy. Palpation and mean size of the evaluated lymph nodes had no predictive value for malignancy. In the 33 cases of non-malignant pathology 9 patients showed patterns of specific infectious disease, including 4 patients with tuberculosis.

Conclusion

Suspicious lymph nodes of the axilla seen on ultrasound rarely indicate occult breast cancer but show a variety of other malignancies and generalised infectious disease requiring further treatment. Fine needle aspiration and/or core needle biopsy are both sufficient methods for clarification in the majority of cases.     

Mammary ductoscopy for the evaluation of nipple discharge and comparison with standard diagnostic techniques

STUDY OBJECTIVE: To describe performance of breast duct endoscopy and compare the method with conventional diagnostic techniques. DESIGN: Canadian Task Force classification III. SETTING: Interdisciplinary Breast Unit of a university hospital. PATIENTS: Consecutive and unselected series of 15 female patients including 20 breasts with nipple discharge. INTERVENTIONS: Prospective data assessment on all patients with ductoscopy for nipple discharge between April 2003 to April 2004. All preoperative (mammography, ultrasonography, nipple smear) and minimally invasive (galactography, fine needle aspiration cytologic study) diagnostics were evaluated and compared with ductoscopy. MEASUREMENTS AND MAIN RESULTS: Mammography on 20 breasts showed BI-RADS-I (5%), BI-RADS-II (50%), and BI-RADS-III (45%). Breast ultrasound scanning showed abnormalities, classified as BI-RADS-III equivalent lesions in all cases. Nipple smear showed in 69.2% a normal cytology and in most cases revealed a papilloma later (n=8/9). Unilateral galactography was performed in 46.7% who had spontaneous nipple discharge. Two galactography results were unremarkable, and open biopsy demonstrated 1 atypical ductal hyperplasia and papilloma. On 20 breasts of 15 women, 19 ductoscopies were successfully performed (95%). In 17 cases open biopsy followed ductoscopy, and 1 ductal carcinoma in situ (DCIS), 3 atypical ductal hyperplasia (ADH), 1 ductal hyperplasia without atypias, and 12 ductal papillomas were found. CONCLUSION: Compared to nipple smear, the diagnostic value of ductoscopy in this study is superior but marginally inferior to galactography and highly specialized breast ultrasound scanning. Therefore ductoscopy needs to be evaluated on a larger scale, preferably in multicenter trials to further determine its potential and indications.     

Infantile/Capillary Hemangioma of the Uterine Corpus: A Rare Cause of Abnormal Genital Bleeding

BackgroundInfantile hemangiomas are vascular anomalies. However, they rarely cause genital bleeding. Here, we present the case of a young female with an endocavitary hemangioma who presented with abnormal uterine bleeding (AUB).CaseThe patient was an 8-year-old female with genital bleeding. Transabdominal pelvic ultrasound showed a 20-mm highly vascularized focal intrauterine endocavitary lesion. Vascular computerized tomography excluded vascular anomalies. Magnetic resonance imaging suggested a hemangioma. Minimally invasive open surgery was performed to remove the lesion. Subsequent pathology analyses confirmed an infantile/capillary hemangioma.ConclusionsInfantile hemangiomas are vascular anomalies that should be considered potential causes of AUB in early puberty. The study of these cases should include pelvic ultrasound and vascular magnetic resonance imaging. Experienced surgeons can successfully accomplish fertility-sparing surgical procedures.SummaryWe describe an unusual case of peripubertal AUB caused by an endocavitary capillary hemangioma. Management included fertility-sparing surgery and the complete resolution of symptoms.     

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.     

The impact of loop diathermy on management of early invasive cervical cancer

Large loop excision of the transformation zone (LLETZ) allows complete histologic assessment of cervical neoplasia. However, selective colposcopically directed punch biopsy followed by local ablation allows the possibility of inappropriate local ablation of early invasive lesions missed at punch biopsy. The onus of accurate diagnosis lies on the colposcopist. We have studied 1143 patients managed with loop diathermy and identified 35 invasive squamous carcinomas and 9 invasive adenocarcinomas. The data show that the cut-off for accurate colposcopic detection of invasive squamous lesions is not breach of the basement membrane but invasion up to a depth of 1 mm. On the other hand, colposcopy is an unreliable guide for the diagnosis of early adenocarcinoma. Diagnosis based on loop excision allows accurate, rational individualization of management for the unexpected diagnosis of colposcopically occult early invasive disease whilst retaining the logistic benefits of a 'see and treat' policy.     

Qualitätsgesicherte Anwendung der Sentinellymphknotenbiopsie beim Mammakarzinom

The sentinel node biopsy is an acknowledged minimally invasive method for the surgical treatment of the early carcinoma of the breast. This technique replaces the conventional axillary lymph node dissection for patients with a small, unifocal and clinically nodal negative breast cancer. However, the success rate of the sentinel node biopsy depends on many factors. Therefore, standards are necessary for the determination, when sentinel node biopsy is indicated, for the technical implementation, for the histopathological work-up and for the therapeutic conclusions from the resulting findings. In 2003 the German Society of Senology created an interdisciplinary consensus regarding the sentinel node biopsy. The recommendations were revised in 2004. This article summarizes the updated guidelines.     

Pregnancy-Associated Breast Cancer: Significance of Early Detection

Pregnancy‐associated breast cancer (PABC) is defined as cancer of the breast diagnosed during pregnancy and up to 1 year postpartum. Delays in diagnosis are frequently associated with increased morbidity and mortality. The aim of this article is to determine the significance of early detection of PABC and to alert health care providers to include PABC in the differential diagnosis when evaluating a breast mass in the perinatal period. This integrative literature review evaluated 15 research studies by using the hypothetical deductive model of clinical reasoning to determine factors related to diagnosis of PABC. As women delay childbearing, the incidence of PABC increases with age. In the reviewed studies, breast cancer was diagnosed with greater frequency in the postpartum period than during any trimester in pregnancy. Delay in diagnosis is complicated by axillary lymph node metastasis, high‐grade tumors at diagnosis, and poor outcomes. Early detection is a significant predictor of improved outcomes. Diagnostic modalities such as ultrasound, mammography, and biopsy can be safely used for diagnostic purposes in the evaluation of potential cases of PABC during pregnancy.     

Needle-localized biopsy of the breast

Our experience with needle-localized biopsy for effective early detection and evaluation of carcinoma of the breast is discussed. Between January 1984 and December 1987, 266 women underwent 279 needle-localized biopsies of the breast performed at a large community teaching hospital. The majority of the women (221 of 266) were found to have benign disease of the breast and 162 of 221 of these were considered to have no increased risk of future carcinoma of the breast as determined by pathologic criteria. Thirty-eight women had primary malignant conditions. Seven patients had recurrent carcinomas after initial treatment with segmental mastectomy. The majority of both the primary and recurrent malignant lesions were infiltrating carcinoma. Using the Fischer exact test, a significant correlation (p less than 0.0004) was found between primary infiltrating carcinoma and a soft tissue mass on mammography. A significant correlation (p less than 0.03) was also found between primary intraductal carcinoma and clustered microcalcifications on mammography. Needle-localized biopsy of the breast provides early detection of carcinoma of the breast and identification of those at risk for subsequent carcinoma of the breast.     

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.     

Vulvar and breast Paget’s disease with synchronous underlying cancer: a unique association

Background  We report a unique case of Paget’s disease of vulva and breast. Sequentially the patient had invasive ductal carcinoma of the breast, 5 years later was diagnosed with vulvar Paget’s with underlying adenocarcinoma and after another 2 years was diagnosed with Paget’s disease of the breast. Case  A 58-year-old woman with invasive ductal cancer of the left breast was treated with lumpectomy, lymph node dissection, radiation therapy and tamoxifen. Five years later and after complaints of longstanding vulvar pruritus, the patient was diagnosed with vulvar Paget’s disease and treated with simple vulvectomy, which revealed a concurrent underlying adenocarcinoma. Subsequently there was recurrence of vulvar malignancy and wide local excision was performed. Seven years after the initial diagnosis of the breast cancer, a biopsy of a left areolar red, ulcerated lesion revealed Paget’s disease of the breast. Conclusion  Physicians need to be cognizant of the rare occurrence of mammary and extramammary Paget’s disease with underlying malignancies in both locations. A thorough physical examination including biopsy is essential for early detection and appropriate management.     

Large-core needle biopsy for diagnosis and treatment of breast lesions

Purpose: Large-core needle biopsy (LCNB) has become a more widely used technique in the evaluation of breast lesions. This study was undertaken to access the accuracy of percutaneous LCNB on breast lesions and the impact on further proceeding. Methods: A retrospective review of imaging-guided LCNB of 159 breast lesions was done. 143 LCNB were taken with ultrasound guided automated spring gun biopsy and 16 stereotactic-guided with vacuum-assisted biopsy device. Histology and morphobiological parameters were compared with subsequent material from surgery. Results: In 113 core biopsies (71%), an infiltrating breast cancer was diagnosed, 5 biopsies (3%) yielded in-situ/atypical lesions and a benign lesion was shown in 38 cases (24%). In 3 cases, insufficient/necrotic material was obtained. 108 patients underwent subsequent surgery. In 100/108 cases (93%), histology on LCNB and surgery was identical. LCNB was false negative in 5 core biopsies (5%). Immunhistochemical stains of hormone receptors, bcl-2, c-erbB-2, p53 and MIB-1 was comparable on LCNB and on surgical material. Based on the results of LCNB, 17/113 patients (15%) with infiltrating carcinoma were primarily treated with hormones or with neoadjuvant therapy. 32/38 patients (84%) with benign lesions were followed up by imaging control. Conclusions: In patients with benign lesions on imaging, open biopsies can be avoided by LCNB. In patients with biopsy proven carcinoma, therapy planning is improved.The addition of morphobiological parameters allows early individual treatment. Received: 29 May 2001 / Accepted: 20 August 2001     

Guidelines on Adenocarcinoma in situ of the Cervix: Clinical Features and Review of Management: These guidelines have been prepared by the SOGC/GOC/SCC Policy and Practice Guideline Committee and were approved by the Council of the SOGC

Cervical intra-epithelial glandular lesions have a morphological spectrum (akin to squamous) that ranges from mild changes to severe abnormalities. The entire spectrum is referred to as “cervical intra-epethilial glandular neoplasia” and is abbreviated as CIGN, CGIN or GIN. The diagnosis of adenocarcinoma in situ (ACIS) is made by some method of excision. The specimen, preferably cylindrical in shape, must have negative (disease free) lateral and upper margins. The ratio of adenocarcinoma in situ to severe squamous dysplasia/carcinoma in situ averages 1:50 (meaning that glandular comprises roughly 2% of in situ cases) whereas the malignant glandular lesions make up six to 18 percent of all invasive cervical cancers. In both stages, 46 to 72 percent of lesions contain a counterpart squamous component (being, therefore, of mixed type).Screening and invasive detection methods used to identify lesions and determine the presence of persistent or recurrent disease (cytology, colposcopy, biopsy and endocervical curettage) are inaccurate and unreliable. This is because of inadequate cytologic sampling in some cases, the existence of various colposcopic mimics (the most commonly encountered being metaplasia, condylomata, invasive adenocarcinoma, invasive squamous cancer and microglandular hyperplasia), most colposcopists’ lack of experience with these lesions (due to their rarity) and the inadequacy of endocervical curettage in some cases.Adenocardnoma in situ has a length (the distance over the tissue surface between caudal and cephalad edges) not usually exceeding 15 mm. The underlying cervical crypt (“gland“) involvement does not usually exceed four millimetres. Although ACIS has many architectural and histological patterns, management is not influenced by these patterns.The management of ACIS continues to be controversial. Cervical excision (like the traditional “conization” but with the specimen cylindrical in shape) is proposed as conservative management for patients desirous of future fertility. The excised specimen must have negative margins, meaning that the outer and upper margins of the specimen are free of disease and that the disease is completely contained within the excised tissue. Follow-up cytology, colposcopy and endocervical curettage may not be accurate in identifying persistent disease and/or detecting recurrent disease. If fertility is not an issue, simple routine hysterectomy is advocated, even though the specimen contains negative margins. Although disease can still be present in the hysterectomy specimen, it is usually ACIS and rarely an invasive adenocarcinoma. In the case of positive margins, meaning disease is noted at the upper and/or outer surface of the excised specimen, the probability of finding an invasive lesion in the extirpated specimen is enhanced.Patients who choose conservative management must be counselled about the importance of compliance and the potential risks of early undetected persistent or recurrent glandular disease, despite negative screening and invasive detection methods. This is because some cases of persistent or recurrent glandular disease have been reported after excision, despite negative specimen margins.