Cost-effectiveness of stereotactic 11-gauge directional vacuum-assisted breast biopsy

OBJECTIVE: The purpose of our study was to determine the frequency with which stereotactic 11-gauge directional vacuum-assisted breast biopsy obviated a surgical procedure and to calculate cost savings attributable to that biopsy method. MATERIALS AND METHODS: We retrospectively reviewed 200 consecutive solitary nonpalpable lesions on which stereotactic 11-gauge directional vacuum-assisted breast biopsy was performed. Cost savings were calculated using Medicare reimbursements. Mammograms, histologic findings, and medical records were reviewed. RESULTS: Stereotactic 11-gauge directional vacuum-assisted biopsy obviated a surgical procedure in 151 (76%) of 200 lesions, including 112 (73%) of 154 calcific lesions and 39 (85%) of 46 masses. Reasons for not obviating a surgical procedure in 49 lesions (25%) included recommendation for surgical biopsy in 35 lesions (18%), small carcinomas treated by excision in 10 lesions (5%), and histologic underestimation in four lesions (2%). Stereotactic 11-gauge directional vacuum-assisted biopsy decreased the cost of diagnosis by S264 per case, a 20% ($264/$1289) decrease in the cost of diagnosis compared with surgical biopsy. Of 200 lesions that had stereotactic 11-gauge directional vacuum-assisted biopsy, 106 (53%) would not have been amenable to 14-gauge automated core biopsy because of their small size, their superficial location, or inadequate breast thickness. CONCLUSION: Stereotactic 11-gauge directional vacuum-assisted breast biopsy obviated a surgical procedure in 76% of lesions, yielding a 20% decrease in cost of diagnosis compared with surgical biopsy. Although savings per case are modest, 11-gauge directional vacuum-assisted biopsy expands the spectrum of lesions amenable to stereotactic biopsy, increasing cost savings in the population.     

Low-cost phantoms for training of stereotactic vacuum-assisted biopsy of the breast

To test low-cost phantoms for training in stereotactic breast biopsy, we prepared eggplant with calcium powder; gelatin and turkey breast with coarse salt, peppercorns, and calcium powder, respectively; and short-bread pastry with salt. Three to 12 cores were harvested with an 11-gauge vacuum biopsy unit. Mammography images were taken before and after biopsy and from the biopsy cores.The pastry phantom provided the best simulation of microcalcifications for stereotactic biopsy with realistic cores, long durability, and short preparation time.     

Epithelial displacement after stereotactic 11-gauge directional vacuum-assisted breast biopsy

OBJECTIVE: Displaced epithelial fragments at percutaneous biopsy of ductal carcinoma in situ (DCIS) may mimic stromal invasion. This study was undertaken to determine the frequency of epithelial displacement in DCIS lesions of patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy. MATERIALS AND METHODS: We retrospectively reviewed 28 consecutive DCIS lesions in patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy followed by surgery. Surgical specimens were examined for histologic evidence of epithelial displacement, consisting of fragments of epithelium in artifactual spaces in breast parenchyma or in lymphovascular channels, accompanied by hemorrhage, fat necrosis, inflammation, hemosiderin-laden macrophages, or granulation tissue. RESULTS: The median number of specimens obtained per lesion was 14 (range, seven to 45). The median interval from stereotactic biopsy to surgery was 27 days (range, 10-59 days). Surgery revealed DCIS in 19 (68%) of 28 lesions, DCIS and infiltrating carcinoma in four lesions (14%), and no residual carcinoma in five lesions (18%). Reactive changes at the biopsy site were identified in all cases. Displacement of benign epithelium into granulation tissue at the stereotactic biopsy site was identified in two cases (7%). We found no evidence of displacement of malignant epithelium. CONCLUSION: Epithelial displacement is uncommon after stereotactic 11-gauge directional vacuum-assisted biopsy of the breast. We observed displacement of benign epithelium in two (7%) of 28 DCIS lesions and no displacement of malignant epithelium.     

Scar formation after stereotactic vacuum-assisted core biopsy of benign breast lesions

AIM: To evaluate scar formation of impalpable breast lesions with benign histological outcome using stereotactic 11-gauge vacuum-assisted core biopsy (VACB). MATERIALS AND METHODS: Two hundred and ten lesions with benign histology for which follow-up mammograms were available, were assessed for scar formation at the biopsy site. All biopsies were performed using stereotactic VACB with 11-gauge needle. The incidence of post-biopsy scar formation and the number of specimens removed were determined. RESULTS: In 4.3% (9/210) of the lesions for which a biopsy was performed with 11-gauge directional vacuum-assisted technique, the follow-up mammogram revealed a scar formation. Of these, six were minimal scars, two were moderate scars and one was a marked scar. Minimal and moderate scars were diagnosed on imaging only. However, the case with marked scar formation required tissue diagnosis to rule out malignancy. CONCLUSION: Although uncommon, scar formation can be seen in the follow-up mammograms after percutaneous breast biopsies. It is important that the radiologist interpreting follow-up mammograms is aware of the features of this lesion and its relationship to the biopsy procedure.     

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

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

Interdisciplinary consensus on the use and technique of vacuum-assisted stereotactic breast biopsy

PURPOSE: Quality assurance of stereotactic vacuum-assisted breast biopsy (VB). METHOD: A consensus was achieved based on the existing literature and the experience of VB users (Ethicon Endosurgery, Norderstedt). RESULTS: The imaging work-up must be completed according to existing standards before an indication for stereotactic VB is established. Indications include microcalcifications and small non-palpable masses; for the time being lesions very close to the skin and architectural distortions (radial scar) are considered less suitable. Acquisition of >20 cores (11 Gauge) should be routinely attempted (goals: as complete a removal of small lesions as possible, thereby increasing diagnostic confidence and reducing so-called 'underestimates'). The pre/post-fire and post-biopsy stereotactic images and a post-biopsy orthogonal mammogram must be documented. All cases with no or uncertain histopathological correlation require discussion in a regular interdisciplinary conference and a documented consensus concerning further work-up or therapy. Standardised documentation of the primary findings and follow-up mammography after approximately 6 months is requested. CONCLUSION: This consensus includes protocols for the establishment of an indication, performance indicators, interdisciplinary interpretation and therapeutic recommendation, documentation and follow-up. It does not replace official recommendations for percutaneous biopsy.     

真空辅助活检装置常见问题的处理体会

目的:探讨真空辅助活检装置(Mammotome)手术常见问题的处理体会。方法:266例患者,329枚乳房肿块,经超声检查诊断均为乳房占位,在超声引导下行麦默通微创旋切治疗。结果:超声引导麦默通微创旋切治疗过程中病变均能清晰显示,引导成功率100%。1例出现皮肤损伤,1例出现切除部位出血、21例出现皮下青紫,发生率5.65%(23/266)。术后3个月超声随访,3例原病灶附近出现新病灶,复发率0.11%。结论:超声引导下麦默通微创旋切手术治疗乳腺肿块具有安全、准确、创伤小、恢复快等优点。     

Percutaneous vacuum-assisted core breast biopsy with upright stereotactic equipment. Indications,limitations and results

Purpose:
To assess the usefulness of stereotactic vacuum-assisted core breast biopsy (VCBB) performed using a stereotactic add-on device and film-screen technology with the patient in an upright seated position. Material and Methods:
We reviewed a series of 129 women with non-palpable mammographic abnormalities who required stereotactic VCBB from December 1999 to November 2000. Twenty-seven (20.9%) cases were excluded due to difficulties in keeping the correct position during the procedure, while the other 102 (79.1%) underwent successful VCBB. Patients with lesions consisting of either atypical ductal hyperplasia or lobular carcinoma in situ were considered for excisional biopsy. Patients with either ductal carcinoma in situ or infiltrating breast cancer were referred for definitive surgery. The results of stereotactic VCBB were correlated to the subsequent surgical histology. Results:
Stereotactic VCBB was interrupted because of bleeding in 1 case and vasovagal reaction in 5 cases. Two haematomas occurred after the procedure. Overall underestimation rate was 10.5%. No new lesions were discovered after a mean follow-up of 18.7 months. Conclusion:
Stereotactic VCBB performed using a standard add-on device with the patient in an upright seated position and analog technology is feasible in about 80% of cases, has a low complication rate, is not significantly time-consuming, and can offer the same accuracy as dedicated prone equipment.     

Clinical experience with MRI-guided vacuum-assisted breast biopsy

OBJECTIVE: The objective of our study was to evaluate a new commercially available method of MRI-guided vacuum-assisted breast biopsy using an open coil and a closed 1.5-T scanner. MATERIALS AND METHODS: Consecutive MRI-guided vacuum-assisted breast biopsies of 38 lesions in 28 women performed between May and September 2003 at two practice sites in the United States were retrospectively reviewed. Lesion characteristics including size, morphology, and enhancement were recorded. Times to perform each procedure, defined as the time from the start of the first localizing scan to the final scan after biopsy, were recorded. Histologic results for all lesions were obtained, and surgical, imaging, or clinical follow-up was performed. RESULTS: Enhancing masses and foci ranged from 2.5 to 19 mm. Nonmasslike enhancements ranged from 6 to 70 mm. All 38 biopsies (100%) were technically successful, and no complications were associated with any of the biopsy procedures. The average time to perform the 19 single-site MRI-guided procedures was 38 min (range, 23-57 min). The 11 multiple-site biopsies performed in a single breast averaged 59 min (range, 51-68 min), and eight bilateral biopsies averaged 64 min (range, 46-80 min). Histologic results from vacuum-assisted breast biopsy revealed malignancy in 14 lesions (37%), atypical ductal hyperplasia in two lesions (5%), and benign findings in 22 lesions (58%). One of two lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery, for an overall cancer yield of 40% (15/38). CONCLUSION: This new method of MRI-guided vacuum-assisted breast biopsy is a safe, effective, and time-efficient means of MRI-guided tissue sampling.     

Impact of stereotactic 11-g vacuum-assisted breast biopsy on cost of diagnosis in Austria

Purpose

To determine the frequency with which stereotactic 11-g vacuum-assisted breast biopsy (11-g SVAB) obviates an open surgical biopsy (OSB), to compare the costs of these two biopsy methods, and to estimate the potential cost savings attributable to 11-g SVAB in the diagnosis of suspicious breast lesions in patients in Austria.

Materials and methods

We retrospectively reviewed 318 consecutive breast lesions of BI-RADS categories IV and V (microcalcifications n = 166; masses n = 152) on which 11-g SVAB and OSB were performed. Cost savings were calculated using nationally allowed flat rates and patient charges. Costs were measured from a hospital and a socioeconomic perspective. Common clinical scenarios and sensitivity analyses assessed the extent of achievable cost savings.

Results

11-g SVAB obviated the need for an OSB in 93 (29%) of 318 women. Overall cost savings per 11-g SVAB over OSB were € 242 per case from a hospital perspective, and € 422 per case from a socioeconomic perspective. The use of 11-g SVAB decreased the cost of diagnosis by 7% from a hospital perspective, and by 10% from a socioeconomic perspective.

Conclusion

In Austria, annual national savings of over 5 million Euro could be realized with the use of 11-g SVAB for the diagnosis of suspicious breast lesions. Although savings per case are modest, the national health care system realizes significant cost reduction as women benefit from a faster and less invasive approach to diagnosis.     

Radiologic-pathological correlation of punctate hyperechoic foci by ultrasound in stereotactic vacuum-assisted breast biopsy samples

Purpose

To correlate punctate hyperechoic foci (PHF) on ultrasound (US) with microcalcifications detected by mammography (MMG) and at histopathology.

Materials and methods

Forty-eight subjects who underwent stereotactic vacuum-assisted breast biopsy (SVABB) for evaluation of breast microcalcifications between April and December 2008 were evaluated for 191 lesions obtained after SVABB. The concordance between PHF on US with microcalcifications detected on MMG and histopathology was therefore evaluated for 191 lesions. Values for sensitivity and specificity were determined against histopathology as the reference standard.

Results

In 154 of 191 samples (80.6%), the PHF on US corresponded with microcalcifications on MMG and histopathology. The overall sensitivity and specificity were 85.3% and 80.0%, respectively, for US, and 89.7% and 90.7%, respectively, for MMG. There were no significant differences between values for US and MMG. At US, 12 PHF did not correlate with any microcalcifications at MMG or histopathology. Histopathology revealed collagen fibers in fatty tissue in 5 of 12 lesions and collagenization in 2 of 12 lesions.

Conclusion

There was a general concordance between PHF on US and microcalcifications detected at MMG. However, in addition to microcalcifications, collagen fibers in fatty tissue and collagenization may account for some PHF. This possibility should be considered when interpreting US findings.     

Nonpalpable breast cancer: percutaneous diagnosis with 11- and 8-gauge stereotactic vacuum-assisted biopsy devices

PURPOSE: To compare the accuracy of diagnosis of invasive breast cancer with 11- and 8-gauge stereotactic vacuum-assisted biopsy (SVAB) devices and to correlate lesion diameter and accuracy of breast cancer diagnosis at SVAB. MATERIALS AND METHODS: During a 22-month period, 489 SVAB procedures were performed with an 11-gauge probe and 305 with an 8-gauge probe. SVAB and surgical pathologic results of 104 breast carcinomas were reviewed and correlated with lesion size, number of specimens obtained, and type of SVAB probe used. RESULTS: Four of 38 ductal carcinoma in situ (DCIS) lesions diagnosed with 11-gauge SVAB demonstrated invasion at surgery, whereas one of 23 DCIS lesions diagnosed with 8-gauge SVAB demonstrated invasion at surgery (P =.6). A mean of 12 specimens per lesion were obtained in each group. In lesions 30 mm or larger, the underestimation rate for DCIS was 43% (three of seven) with 11-gauge SVAB and 17% (one of six) with 8-gauge SVAB (P =.6). Overall, the rate of underestimation for DCIS was significantly higher in lesions 30 mm or larger (four of 13) than in smaller lesions (one of 48, P =.006). CONCLUSION: This study demonstrated no difference in breast cancer diagnosis with the 8- and 11-gauge SVAB systems, but the accuracy of breast cancer diagnosis was greater in lesions smaller than 30 mm than in larger lesions.     

Retrieval of lost microcalcifications during stereotactic vacuum-assisted core biopsy

OBJECTIVE: The purpose of our report was to describe patients in whom calcifications in the breast that were unequivocally removed during stereotactic core biopsy using the Mammotome device were not detected on the initial specimen radiograph. The lost calcifications in each instance were subsequently found when the tubing and contents of the debris canister were strained through a nonadhering dressing and radiographed. Additional situations in which calcifications are not seen on the initial specimen radiograph are described and recommendations are made. CONCLUSION: When vacuum-assisted core biopsy procedures are performed, it is important to be aware of the possibility that calcifications may be aspirated into the debris canister, thus compromising the accuracy of the histopathologic diagnosis. We recommend changing the tubing and the debris canister after each procedure and, in certain situations, sending the strained canister contents to pathology for evaluation.     

MRI-guided vacuum-assisted breast biopsy with a handheld portable biopsy system

OBJECTIVE: The purpose of this study was to evaluate a compact portable 10-gauge handheld battery-operated vacuum-assisted biopsy system for MRI-guided breast biopsy. CONCLUSION: The compact portable battery-operated biopsy system can be used successfully for MRI-guided core breast biopsy and is an alternative to current systems.     

11-gauge vacuum assisted directional biopsy of breast calcifications, using upright stereotactic guidance

To assess the use of a prototype vacuum assisted biopsy device on a standard upright mammography unit, using a slightly modified digital stereotactic add-on component. A group comprised of 42 sequential patients, who had been recalled from an asymptomatic mammographic screening programme, were studied. All 42 were recalled for assessment of small clusters of microcalcification, graded as indeterminate. Group 1 (21 patients) were biopsied using 14-gauge automated large core needle biopsy. Group 2 (21 patients) were biopsied using 11-gauge vacuum assisted biopsy. Both groups had mammographic guidance on the same upright mammographic unit (Siemens 3000), with Opdima Digital Stereotactic add-on. A total of 86% of specimen radiographs in Group 2 patients (vacuum assisted biopsy) showed successful sampling of the calcifications, compared to 62% of Group 1 patients (14-gauge automated large core biopsies). This study shows that vacuum assisted biopsy is possible using upright stereotactic mammography units. The technique shows promise as a biopsy tool, offering larger cores compared to 14-gauge automated large core biopsy, while requiring less space and lower purchase price compared to dedicated prone biopsy tables. The technique also offers access to biopsy in patients with posterior lesions and for patients who cannot tolerate prone positioning.     

Biopsy of amorphous breast calcifications: pathologic outcome and yield at stereotactic biopsy.

PURPOSE: To assess the pathologic outcome of amorphous breast calcifications and the success of stereotactic biopsy for such lesions. MATERIALS AND METHODS: From July 1995 through February 2000, biopsy of all clustered amorphous calcifications not clearly stable for at least 5 years or in a diffuse scattered distribution was recommended. Logistic regression analysis was used to stratify the risk of malignancy by patient risk factors, calcification distribution, and stability. RESULTS: Calcifications were retrieved from 150 biopsies; 30 (20%) proved malignant and included 27 ductal carcinomas in situ and three low-grade invasive and intraductal carcinomas (2-5 mm). Another 30 (20%) yielded high-risk lesions, including 21 atypical ductal hyperplasia, eight atypical lobular hyperplasia, and one lobular carcinoma in situ. In 150 lesions, stereotactic biopsy was performed on 113 and aborted in 10. Calcifications were retrieved from all 113 stereotactic biopsies. Of those with calcification retrieval, there were three histologic underestimates (accuracy, 97%). Stereotactic biopsy spared a surgical procedure in 57 (46%) of 123 patients. Needle localization was required for 23 (15%) of 150 patients due to poor conspicuity. Five (45%) of 11 biopsies performed in women with ipsilateral breast cancer showed malignancy (P = .025). When multiple lesions of amorphous calcifications were present in one breast, sampling of one reliably predicted the outcome of others. CONCLUSION: We found a substantial rate of ductal carcinoma in situ and high-risk lesions associated with amorphous calcifications. Stereotactic biopsy can be successfully performed for the majority of subtle amorphous calcifications; however, only a minority were spared a surgical procedure.