Large-Gauge Core Needle Biopsy of the Breast

Abstract: Large-gauge core needle biopsy (LGCNB) of the breast is gaining acceptance as a viable alternative to surgical excision. The procedure can be performed efficiently using ultrasound or stereotactic guidance. We report our experience with 137 LGCNB performed over a 40-month period. One hundred thirty-seven lesions in 125 patients were subjected to LGCNB. Fifty-nine procedures were performed using stereotactic guidance and 78 using ultrasound guidance. Stereotactic procedures utilized a prone table and ultrasound procedures used a freehand technique. All biopsies were performed with a 14-gauge core needle attached to an automated biopsy device. There were 53 malignant and 84 benign diagnoses in this group of 137 LGCNB. Surgical correlation is available in 46 of the 53 malignant cases. There were no false positives, though one lesion was missed at the initial surgical excision but retrieved at reexcision. Of the 84 benign cases, there has been surgical (n = 10) or mammographic follow-up (n = 32) in 42. The mean duration of mammographic follow-up is 13 months (range: 5–36 months). There was one false negative LGCNB. The sensitivity, specificity, positive predictive value, and negative predictive value in this series are 98%, 100%, 100% and 96%, respectively. LGCNB has a high degree of accuracy and is well accepted by patients. There are some persistent difficulties with the technique, such as ensuring compliance with follow-up recommendations among patients with benign results and excluding invasive carcinoma.?     

MRI‐Guided Breast Needle Core Biopsies: Pathologic Features of Newly Diagnosed Malignancies

Magnetic resonance imaging (MRI) of the breast is used for select groups of patients. MRI‐guided breast core needle biopsies performed over a 3‐year period were retrospectively reviewed to determine the incidence and types of cancers found and to correlate the cancers with the MRI findings and the indication for the study. Patients were stratified based on indication for MRI examination including, evaluation of disease extent in patients with current ipsilateral carcinoma, surveillance for recurrence of prior ipsilateral carcinoma, as a problem‐solving method and for screening high‐risk patients. The high‐risk screening group included those with family history (with or without germline mutations), prior chest wall radiation, and contralateral breast carcinoma (current or prior). Four‐hundred and forty‐five biopsies were performed on 386 patients. The majority of biopsies (79%) were benign. Biopsies demonstrating ductal carcinoma in situ (DCIS) and invasive carcinoma were more likely to present as nonmass‐like and mass‐forming enhancements respectively, but with only 52% specificity. The highest rate of malignancy (44%) was seen in the least frequently biopsied patient group (n = 25), those with prior ipsilateral carcinoma. Conversely, the most frequently biopsied group (n = 283), the high‐risk screening group, demonstrated the lowest malignancy rate (16%). Within this group, most malignant cases were invasive carcinomas (n = 27), 67% of which were small (≤1 cm), well or moderately differentiated with a good prognostic receptor profile (estrogen receptor positive, human epidermal growth factor receptor 2 negative), and lacked nodal macrometastases. The remaining malignant cases in the high‐risk screening group were DCIS with or without microinvasion (n = 18), 78% of which demonstrated high nuclear grade. Overall, enhancement pattern did not correlate with the likelihood of or type of malignancy. The most common types of carcinomas identified by screening were small estrogen receptor positive invasive tumors and high grade DCIS.     

Histomorphologic Features of Biopsy Sites Following Excisional and Core Needle Biopsies of the Breast

Mammographic studies have documented a number of architectural changes occurring around breast biopsy sites. These changes are well described in the radiological literature, but similar studies do not appear to be present in the pathology literature. We reviewed 100 consecutive mastectomy specimens from women who had undergone prior core needle or excisional biopsies. Multiple sections of the needle tract or excisional biopsy site were reviewed and morphologic findings reported. Hemorrhage, fat necrosis, granulation tissue, necrosis of fibrous tissue, and epithelium along with fibrosis and foreign body type giant cells were common features. Less frequent were areas of synovial metaplasia, atypical spindle cells, atypical duct‐like structures, single atypical cells, squamous metaplasia, proliferations of abnormal blood vessels, and hemosiderin deposition. The misinterpretation of atypical spindle cells, single atypical cells, atypical duct‐like structures and squamous metaplasia could result in the false‐positive diagnosis of residual malignancy. Careful attention to the reactive nature of these changes aids in their distinction from carcinoma.     

Multicentric Secretory Carcinoma of the Breast in a 35-Year-Old Woman: Mammographic Appearance and the Use of Core Biopsy in Preoperative Management

Abstract: Core biopsy of the breast has been increasingly utilized as a first-line diagnostic approach for mammographic breast lesions, palpable breast lesions, or both. Core biopsy has been shown to be cost-effective in sparing a significant fraction of women an open surgical procedure and, in conjunction with radiologic imaging studies, can allow for planning of definitive therapy in women with malignant lesions ( 1 - 4 ). We present a case of multicentric secretory carcinoma of the breast in which the diagnosis was suggested by core biopsy. This case represents the first reported instance of core biopsy in secretory carcinoma, one of the rarest types of mammary carcinoma. We describe the mammographic appearance of the lesion, the appearance of the tissue core, and the use of core biopsy in the proper preoperative management of this rare, multicentric lesion.     

Breast Papillomas in the Era of Percutaneous Needle Biopsy

Background The significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history. Methods In this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed. Results Between January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively. Conclusions Benign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.     

The Management of Benign Concordant MRI‐guided Breast Biopsies: Lessons Learned

After benign concordant magnetic resonance imaging (MRI)‐guided breast biopsy, initial follow‐up MRI at 6 months is often recommended for confirmation. This study was undertaken to determine the proper management of stable lesions on initial follow‐up MRI and whether such follow‐up can be safely deferred to 12 months. Retrospective review of 240 MRI‐guided biopsies identified 156 benign concordant lesions. 85 eligible cases received follow‐up MRI and constitute the study population. On initial follow‐up MRI, 72 of 85 lesions appeared adequately sampled, 12 were stable and underwent further MRI follow‐up, and 1 was benign on subsequent surgery. No cancers were diagnosed at the biopsy sites on either 6‐ or 12‐month follow‐up MRI. Among the 12 stable lesions, four were masses and eight were nonmass enhancements. One of the stable masses enlarged on 24‐month follow‐up MRI and proved malignant. All stable nonmass lesions were benign on long‐term follow‐up. After benign concordant MRI‐guided breast biopsy, a stable mass has a 25% probability of malignancy in our series. Re‐biopsy of such masses should be strongly considered. Stable nonmass lesions may be followed with subsequent MRI without rebiopsy. Deferral of initial follow‐up MRI to 12 months may be acceptable.     

Infrared Imaging Does Not Predict the Presence of Malignancy in Patients with Suspicious Radiologic Breast Abnormalities

The NoTouch BreastScan (NTBS) is a non‐invasive infrared imaging device which measures thermal gradients in breasts using dual infrared cameras and computer analysis. We evaluated NTBS as a predictor of breast cancer in patients undergoing minimally invasive biopsy. In this IRB‐approved prospective trial, 121 female patients underwent NTBS prior to scheduled tissue biopsy. Twenty‐two patients were excluded due to uninterpretable scans (n = 18), diagnosis of a nonprimary breast malignancy (n = 1), or no biopsy performed (n = 3) for a total of 99 patients. Five patients had bilateral breast biopsies and one patient had two ipsilateral biopsies, resulting in 105 biopsies. Patients were prospectively scanned using a high specificity mode, termed NTBS1. All 99 patients were retrospectively re‐evaluated in a high sensitivity mode, NTBS2. Of 105 biopsies performed in 99 women, 33 (31.4%) were malignant and 72 (68.6%) were benign. NTBS1 demonstrated a sensitivity of 45.5% and a specificity of 88.9%. Of 94 normal contralateral breasts, 9.6% had a positive NTBS1. In the retrospective evaluation, NTBS2 demonstrated a sensitivity of 78.8% and a specificity of 48.6%. Half (50%) of the normal contralateral breasts had a positive NTBS2. NTBS does not accurately predict malignancy in women with suspicious imaging abnormalities. The higher sensitivity mode results in an unacceptable number of false positives, precluding its use. Infrared imaging did not improve the sensitivity or specificity of mammography in this clinical setting.     

Downstaging of Breast Carcinomas in Older Women Associated with Mammographic Screening

The efficacy of mammographic screening for older women has not been well studied. The present study was designed to evaluate for downstaging of breast carcinomas associated with mammographic screening in older women. The study population consisted of 130 women age >/=65 years with newly diagnosed breast carcinoma in 1993-1994 and was obtained from women enrolled in a large health maintenance organization. Mammographic screening, if done, was performed by a network of predominantly community-based radiologists. Significant downstaging was found for the breast cancers detected in women who had undergone mammographic screening compared to the breast cancers detected in women who had not undergone mammographic screening. The American Joint Committee on Cancer (AJCC) clinical stage was stage 0 and stage I in 7% (8/107) and 73% (78/107), respectively, of the breast cancers detected in women who had undergone mammographic screening compared to 0% (0/23) and 22% (5/23), respectively, of the breast cancers detected in women who had not undergone mammographic screening (p < 0.0001). Clinical Tis and T1 tumors were found in 7% (8/107) and 74% (79/107), respectively, of the breast cancers detected in women who had undergone mammographic screening compared to 0% (0/23) and 22% (5/23), respectively, of the breast cancers detected in women who had not undergone mammographic screening (p < 0.0001). Of the 102 AJCC clinical stage I-II breast cancers with known pathologic axillary lymph node staging, lymph node stage was N0 for 76% (66/87) of the women who had undergone mammographic screening compared to 53% (8/15) of the women who had not undergone mammographic screening (p = 0.019). The results of downstaging reported in this study are important because earlier staged lesions are associated with an improved prognosis and an increased potential for breast-conservation treatment. These findings have shown that mammographic screening is effective in downstaging breast carcinomas found in older women.     

First Report of a Necrotising Fasciitis of the Breast Following a Core Needle Biopsy

Abstract:  Necrotising fasciitis (NF) is the most aggressive form of soft tissue infection. We report the first case of NF of the breast following a core needle biopsy. Aggressive management including surgical debridement and vacuum therapy allowed wound healing and breast conservation.     

The Importance of Preoperative Breast MRI for Patients Newly Diagnosed with Breast Cancer

Abstract:  The use of preoperative breast magnetic resonance imaging (bMRI) for patients newly diagnosed with breast cancer has been criticized for increasing the number of therapeutic mastectomies performed, as well as increasing the cost of treatment. The purpose of this report is to examine one surgeon's practice and to describe the MRI findings for patients with breast cancer to determine if those findings changed the therapeutic options for those patients in. Data were collected prospectively between August 2003 and January 2006 for patients newly diagnosed with breast cancer. Diagnoses were made by core biopsy or fine-needle aspiration; all lesions were intact at the time of MRI. Twenty-five percent of patients were found to have previously occult, but suspicious lesions on MRI that required additional diagnostic evaluation, including ultrasound, core biopsy, excisional biopsy, or any combination; for approximately half of these patients a separate cancer was confirmed. For most of these patients, the new lesion was ipsilateral and multicentric, and most required mastectomy. For the remaining 75% of patients, MRI confirmed the index lesion was the only area of concern, and appropriate surgical treatment was completed. Preoperative bMRI for patients newly diagnosed with breast cancer identified previously occult and separate tumors in 13% of patients, resulting in surgical treatment change for many.     

Breast MRI in the Evaluation of Patients with Occult Primary Breast Carcinoma

▪ Abstract: Occult primary breast carcinoma presenting as isolated ipsilateral axillary lymph node metastases in patients with normal mammograms and normal physical exams accounts for less than 1% of all breast carcinomas. Contrast-enhanced magnetic resonance imaging (MRI) may identify the site of primary breast carcinoma and effect management of these patients. We report on eight consecutive women evaluated in our multidisciplinary clinic who had biopsy-proven metastatic adenocarcinomas to axillary lymph nodes and occult primary carcinomas. Each patient underwent MRI at 1.5 T with a volumetric fast-spoiled gradient-echo (3D FSPGR) pulse sequence before and after injection of gadopentetate dimeglumine. Wire localization of suspicious areas of enhancement was performed under MRI or mammography guidance followed by surgical excision. Seven (88%) of the eight normal mammograms showed dense (>50%) breast parenchyma. In two (25%) of the eight patients, suspicious focal or regional enhancement was seen on MRI. Following wire localization and excision, pathologic exam showed an invasive ductal carcinoma and ductal carcinoma in situ with invasion corresponding to the MRI enhancement in the two cases. Breast MRI can identify the primary tumor site and influence management of patients presenting with clinically and mammographically occult primary breast carcinomas. ▪     

Ductal carcinoma in situ and atypical ductal hyperplasia of the breast diagnosed at stereotactic core biopsy

Abstract: Stereotactic core needle biopsy (SCNB) allows specific histopathologic diagnoses to be made without surgery and has been demonstrated to be an accurate, cost-effective method of diagnosing breast disease, particularly nonpalpable lesions. However, recent studies have concluded that the diagnosis of atypical ductal hyperplasia (ADH) by means of SCNB has resulted in nearly equal odds that a coexisting malignant lesion will be missed. Furthermore, others have concluded that SCNB diagnosed as DCIS cannot reliably indicate the absence of tumor invasion in surgical excision. Between 1993 and 1998, 1,221 consecutive SCNB of mammographically identified lesions were performed using a 14-gauge automated device with an average of 5.3 cores obtained per lesion. ADH was identified in 19 (1.6%) lesions and DCIS in 89 (7.3%). Surgical biopsy was performed in 89 of these patients and histopathologic results from SCNB and surgical biopsies were reviewed and correlated. In 12 cases of ADH diagnosed by SCNB, surgical biopsy showed ADH in 8 (67%) cases and DCIS in the other 4 (33%) cases. In 77 cases of DCIS diagnosed by SCNB, a surgical biopsy showed DCIS in 55 (71%) cases, 6 more cases (8%) had DCIS with focal microinvasion, and 15 (19%) had invasive ductal carcinoma. In one case no residual tumor was found at surgery. In the author's patient population, the diagnosis of ADH at SCNB indicates high probability of DCIS or residual ADH in the surgical biopsy. The diagnosis of DCIS at SCNB is confirmed in the majority of surgical biopsies; however, a significant number of cases may show microinvasion or invasive carcinoma.     

The Utility of Breast MRI in the Management of Breast Cancer

Abstract: Breast magnetic resonance imaging (MRI) is increasingly used in the evaluation of breast cancer. The impact of this modality on patient management at a single institution is evaluated in this paper. A retrospective review was performed for 114 breast cancer patients who had breast MRI as part of their diagnostic evaluation. Clinical information, mammograms, breast ultrasounds and MRI scans were reviewed to determine whether the MRI findings led to a change in patient management. Outcomes as the result of breast MRI were stratified as favorable and unfavorable. Ninety‐five patients who had complete clinical, radiologic, and pathologic data were identified. The indications for breast MRI included: high risk screening (n = 3), diagnostic evaluation of disease after neo‐adjuvant chemotherapy (n = 24) or prior to re‐excision (n = 8), extent of in situ ductal, infiltrating ductal or infiltrating lobular disease histology (DCIS n = 3, IDC n = 24, ILC n = 17), identification of unknown primary (n = 2), assessment of contralateral breast (n = 4), recurrence surveillance (n = 5), and other (n = 5). MRI was concordant with clinical findings and other modalities in 70.5% of cases. MRI altered planned clinical management in 28 of 95 patients (29.5%). Management changes were favorable in 21 patients (75%). Diagnostic evaluation of the breast by MRI alters patient management in 30% of cases depending upon the indications. Alteration in patient management is favorable in 75% of cases. Evaluation of the breast by MRI alters the clinical management of nearly one‐third of patients. Changes are favorable for the majority of these cases. Patients undergoing evaluation for contralateral disease, invasive lobular carcinoma and assessment of chemotherapeutic response may derive a more meaningful benefit from MRI.     

Breast‐Specific Gamma Imaging Influences Surgical Management in Patients with Breast Cancer

Breast‐specific gamma imaging (BSGI) is a physiologic breast imaging modality that provides more sensitive detection of breast lesions than mammography or ultrasound, and appears to have greater specificity than breast MRI. The purpose of this study was to evaluate how often BSGI changed surgical management in patients with breast cancer. Charts were reviewed from 218 consecutive eligible patients who had preoperative evaluation with BSGI or MRI before surgery for breast cancer from January 2008 to May 2010. Patients who were initially considered eligible for breast‐conserving therapy (BCT) were evaluated to determine how many ultimately had mastectomies. Patients who underwent mastectomy because of personal choice or ineligibility for BCT were excluded. Management was changed to mastectomy in 11.9% of those who had BSGI and 28.9% of those who had MRI. Review of pathology demonstrated that all patients who underwent mastectomies were not candidates for breast conservation. 15.4% of patients who underwent BCT based on BSGI findings required a single re‐excision due to positive surgical margins. 14.4% required mastectomy. In the MRI group, 18.8% required a single re‐excision, and 6.3% required mastectomy. Evaluation with BSGI changed management to mastectomy in a substantial proportion of patients believed to be eligible for BCT following standard imaging. BSGI is effective in evaluation of extent of disease in patients with breast cancer, and is comparable to MRI in terms of its influence on surgical management.     

Atypical Ductal Hyperplasia in Stereotactic Breast Biopsies: Enhanced Accuracy of Diagnosis with the Mammotome

Abstract: There is little literature assessing the incidence of subsequent carcinoma in patients diagnosed with atypical ductal hyperplasia (ADH) by mammotome. We reviewed 216 stereotactic mammotome biopsies (SMBs) and compared the results to the 121 automated tru-cut biopsies (ATC) performed at our breast care center from June 1994 to July 1998. The median age in the mammotome series was 57 years, compared to 56 years in the ATC group. An increase in biopsies for microcalcifications (49% versus 41%) was noted in the SMB series. This was accompanied by an increase in the number of cases with a diagnosis of pure ductal carcinoma in situ (DCIS) (10% versus 4%). Compared to the tru-cut, in which 38% (3 of 8) of the cases diagnosed as atypical hyperplasia (AH) showed DCIS and/or invasive carcinoma on open biopsy, none of the cases diagnosed as AH on mammotome revealed carcinoma on open biopsy. ADH is more accurately diagnosed with SMB than by the ATC method and may not be an indication for subsequent open biopsy.     

乳癌病人癌因性疲乏的评估与处理

目的探讨适合乳癌病人癌因性疲乏的评估量表及处理方法。方法对 4 0例综合治疗期的乳癌病人应用欧洲癌症治疗与研究组织问卷、简易疲乏量表、卡氏功能量表进行癌因性疲乏评估 ,对癌因性疲乏病人采取心理疏导、健康教育、有氧运动、增加营养及中药治疗 10d后再进行疲乏程度评估。结果 3种评估量表评估的病人疲乏程度比较 ,差异无显著性意义 (χ2 =1.17,P >0 .0 5 ) ,4 0例病人治疗后疲乏程度显著减轻 (χ2 =4 8.36 ,P <0 .0 1)。结论 3种量表均适合乳癌病人癌因性疲乏的评估 ,心理疏导、健康教育、有氧运动、营养及中药治疗可以消除疲乏或缓解疲乏程度。     

Role of Breast Ultrasound and Mammography in Evaluating Patients Presenting with Focal Breast Pain in the Absence of a Palpable Lump

To determine if ultrasound and/or mammography is helpful in detecting breast cancers in patients presenting with focal breast pain. Patients who presented between February 2008 and April 2011 with focal breast pain without a lump were included in the study. The mammographic and US findings were retrospectively reviewed. BIRADS 0, 4, and 5 were considered positive on mammogram while BIRADS 4 and 5 were considered positive on US. The efficacy of mammogram‐alone, ultrasound‐alone, and in combination to detect breast cancer was evaluated. The performance of mammography for detecting any mass lesions that were present on subsequent US was also evaluated. A total of 257 patients were evaluated with US and 206 (80.1%) of these also had mammograms prior to the US. Cancer incidence was 1.2% (n = 3). The sensitivity, specificity, PPV, and NPV of mammogram‐alone and US‐alone for detection of breast cancer in these patients were 100%, 87.6%, 10.7%, 100% and 100%, 92.5%, 13.6%, and 100%, respectively, while for combined mammogram and US was 100%, 83.7%, 8.3%, and 100%. The sensitivity, specificity, PPV, and NPV of mammogram for identifying an underlying suspicious mass lesion that was subsequently detected by US was 58%, 91%, 39%, and 95%. The NPV of a BIRADS 1 mammogram for any underlying mass lesion was 75%. Addition of an ultrasound to a mammogram did not detect additional cancers; likely due to low cancer incidence in these patients. However, US detected underlying mass lesions in 25% cases with a BIRADS 1 mammogram result.     

风险管理策略在乳腺癌化疗患者护理中的应用

目的探讨对乳腺癌化疗患者实施护理风险管理的效果。方法将170例乳腺癌化疗患者根据住院时间分为对照组（80例）和观察组（90例），对照组按常规实施化疗方案，出现化疗风险时予以对症处理；观察组实施化疗方案时根据建立的风险管理流程对患者的护理风险进行识别、分析和预防。结果两组护理缺陷、投诉情况、患者满意度及化疗期间护理风险发生情况比较，差异有显著性意义（均P〈0．05）。结论对乳腺癌化疗患者实施风险管理可提高护理人员对化疗风险的认识，减少护理缺陷和投诉，降低护理风险，提高患者满意度。