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

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

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

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

Breast tissue bulge and lesion visibility during stereotactic biopsy – A phantom study

BackgroundDuring mammography guided stereotactic breast biopsy a bulge of tissue can form in the paddle needle biopsy aperture. This bulge has been estimated to have a height of up to 30% of the breast itself. During clinical biopsy we have noticed that lesions can appear to be less visible when tissue bulges are evident. This can make biopsy more difficult in some cases.ObjectivesThis experiment investigates how lesion visibility varies with breast bulge magnitude.MethodUsing a phantom to represent breast and breast bulge, lesion visibility was assessed using a two alternative forced choice methodology. To mimic clinical conditions, imaging was performed on a full field digital mammography system with the biopsy paddle attached using an automatic exposure device. Organ dose (breast) was estimated.ResultsAs breast bulge increases lesion visibility decreases; organ dose increases as breast bulge magnitude increases.ConclusionConsideration should be given to the impact of breast bulge magnitude and lesion visibility when performing image guided biopsy.Advances in knowledgeThe authors found no similar studies and the results of this study demonstrate a potential clinical risk.     

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

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

Ductal carcinoma in situ diagnosed with stereotactic core needle biopsy: can invasion be predicted?

PURPOSE: To determine whether mammographic or histologic features can be used to predict which cases diagnosed as ductal carcinoma in situ (DCIS) without invasion by means of stereotactic core needle biopsy (SCNB) will have invasive disease at surgery. MATERIALS AND METHODS: From July 1992 to March 1999, DCIS without invasion was diagnosed by means of SCNB in 59 patients. Seventeen (29%) were found to have invasive disease after surgery. The underestimation rate for SCNB was compared with that obtained by means of open surgical biopsy. Mammographic and histologic features of cases with and those without invasion were compared. RESULTS: All patients had calcifications on mammograms. There was no significant difference (P: =.26) between the underestimation rate for SCNB with the 11-gauge vacuum-assisted device and that for open surgical biopsy. No statistically significant differences between cases with and those without invasion were seen in patient age, mean number of core specimens, level of suspicion, size of lesion, distribution and morphology of the calcifications, presence of an associated mass or density, subtype of DCIS, nuclear grade, or presence of necrosis or desmoplasia. CONCLUSION: Mammographic and histologic features cannot be used reliably to predict cases that are underestimated with SCNB. However, SCNB with the 11-gauge vacuum-assisted device was as reliable as open surgical biopsy for diagnosing DCIS without invasion.     

Complete percutaneous excision of infiltrating carcinoma at stereotactic breast biopsy: how can tumor size be assessed?

OBJECTIVE: The purpose of this study was to determine the frequency of complete excision of infiltrating carcinoma at stereotactic 11-gauge directional vacuum-assisted breast biopsy and to evaluate the feasibility of measuring tumor size in stereotactic biopsy specimens in infiltrating carcinomas that were percutaneously excised. MATERIALS AND METHODS: We performed retrospective review of 51 infiltrating carcinomas diagnosed using stereotactic 11-gauge directional vacuum-assisted biopsy that underwent subsequent surgery. For lesions yielding no residual infiltrating carcinoma at surgery, the maximal dimension of the tumor was measured in stereotactic biopsy specimens using ocular micrometry. RESULTS: In 10 (20%) (95% confidence intervals, 9.8-33.1%) of 51 infiltrating carcinomas diagnosed at stereotactic biopsy, surgery revealed no residual infiltrating carcinoma. Complete excision of infiltrating carcinoma was more frequent if 14 or more specimens were obtained (32% versus 0%, p < .004), if the mammographic lesion was removed (35% versus 7%, p < .03), and if the mammographic lesion size measured 0.7 cm or less (50% versus 16%, p = .08). Tumor size in stereotactic biopsy specimens was within 3 mm of mammographic lesion size in six (60%) of 10 lesions, including five (71%) of seven masses and one (33%) of three calcification lesions, but was smaller than the mammographic lesion size in eight (80%) of 10 lesions. CONCLUSION: Surgery revealed no residual infiltrating carcinoma in 10 (20%) of 51 infiltrating carcinomas diagnosed at stereotactic 11-gauge biopsy. Although tumor size can be assessed in stereotactic biopsy specimens in these lesions, such measurements may underestimate the maximal dimension of the tumor. Further study is needed to evaluate the usefulness of these measurements in guiding treatment decisions.     

To excise or to sample the mammographic target: what is the goal of stereotactic 11-gauge vacuum-assisted breast biopsy?

OBJECTIVE: This study was undertaken to determine whether complete percutaneous excision rather than sampling of the mammographic target conveys any significant advantage or disadvantage at stereotactic 11-gauge vacuum-assisted biopsy. MATERIALS AND METHODS: A retrospective review was performed of 788 consecutive solitary lesions in which the mammographic target was excised (n = 466) or sampled (n = 322) at stereotactic 11-gauge vacuum-assisted biopsy. Medical records and histologic findings were reviewed to determine the frequency of sparing surgery, discordance, histologic underestimation, rebiopsy, complete histologic removal of cancer, and complications. Statistical comparisons were made using the Fisher's exact test. RESULTS: Complete excision rather than sampling of the mammographic target was associated with a significantly lower frequency of discordance (1/466, 0.2% vs 8/322, 2.5%; p = 0.004) and a trend toward fewer ductal carcinoma in situ underestimates (4/59, 6.8% vs 12/60, 20.0%; p = 0.07). Complete histologic removal of cancer was significantly more likely if the mammographic target was excised rather than sampled (19/91, 20.9% vs 7/106, 6.6%; p = 0.006); however, among 91 cancers in which the mammographic target was excised, surgery revealed residual cancer in 72 (79.1%). Complete excision rather than sampling of the mammographic target yielded no significant differences in the frequency of sparing surgery, atypical ductal hyperplasia underestimates, rebiopsy, or complications. CONCLUSION: Complete excision rather than sampling of the mammographic target was associated with lower frequencies of discordance and ductal carcinoma in situ underestimation but had no other advantage or disadvantage. Among cancers in which the mammographic target was excised, surgery revealed residual cancer in almost 80%.     

Evaluation of stereotactic core biopsies of the breast with the 10-gauge Vacora® biopsy device: a review of 541 procedures

Purpose

To evaluate stereotactic core biopsies of the breast with the 10-gauge Vacora^® biopsy device.

Patients and methods

Retrospective study of 541 procedures in 502 patients performed between 2007 and 2009.

Results

The procedure failed in 2 % of cases, non-complicated hematomas occurred in 5 % of cases and unsightly scars in two cases. A clip was deployed in 70 % of cases, successfully in 99 % of cases. The procedure was well tolerated in 88 % of cases. Core biopsies confirmed a benign lesion in 55 % of cases, borderline lesions in 19 % of cases and malignant lesions in 26 % of cases with complementary surgery performed in 40 % of cases. For surgical lesions, sensitivity, specificity, PPV and NPV were 89 %, 100 %, 100 % and 84 % respectively. Atypical ductal dysplasia was under-estimated in 8 % of cases while DCIS was under-estimated in 14 % of cases. After review of the mammograms, 3 % of Bi-Rads 4 lesions were reclassified as Bi-Rads 3 lesions, all benign at core biopsy. Half of these results were from screening mammography programs.

Conclusion

Results with the 10-gauge Vacora^® biopsy device are similar to reports from the literature, mainly using the Mammotome system, with regards to tolerability and reliability for a lesser cost.     

Trans-caval trans-jugular liver biopsy—a technical modification of trans-jugular liver biopsy

Objective:

To (a) describe the technical modification of trans-caval TJLB and (b) review our series of nine cases.

Methods:

We performed a retrospective review of all trans-caval TJLBs performed; we assessed indications for the procedure, technical success, complications, adequacy of specimen and histological positivity.

Results:

The technical success rate of the procedure was 9/9 (100%); the minor complication rate was 1/9 (11%), adequate specimen was obtained in all cases and a histological diagnosis was achieved in 8/9 (89%) cases.

Conclusion:

This preliminary report suggests that trans-caval modification of TJLB is a relatively safe procedure that may be useful in cases where conventional TJLB is infeasible.

Advances in knowledge:

(a) We describe the technique of trans-caval TJLBs and report our findings in the largest series of published cases. (b) Trans-caval TJLB is relatively safe and can be used to increase the success rates of conventional TJLB.Trans-jugular liver biopsy (TJLB) is an established technique in patients unsuitable for a percutaneous trans-abdominal liver biopsy. TJLB procedure involves biopsy of the liver parenchyma through trans-jugular venous access, with the biopsy needle placed in the right hepatic vein (commonly described) or the middle or left hepatic veins. However, a TJLB may be not technically feasible in a small subset of cases where hepatic venous cannulation is not possible, owing to unsuitable hepatic venous anatomy, occluded hepatic veins [Budd–Chiari syndrome (BCS)] or markedly shrunken liver. In such cases, a technical modification of TJLB, called a direct trans-caval TJLB, can be performed. In this study, we (a) describe the technical modification of the trans-caval TJLB and (b) review the results of a series of nine cases where the trans-caval TJLB was carried out.     

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Key Points

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

     

Atypical ductal hyperplasia: can some lesions be defined as probably benign after stereotactic 11-gauge vacuum-assisted biopsy,eliminating the recommendation for surgical excision?

PURPOSE: To determine if a subset of atypical ductal hyperplasia (ADH) lesions diagnosed at 11-gauge, directional, vacuum-assisted, prone, stereotactic biopsy fit the "probably benign" definition of a less than 2% chance of being carcinoma at subsequent surgical excision. MATERIALS AND METHODS: Clinical, mammographic, and stereotactic biopsy features in 104 consecutive nonpalpable ADH lesions were correlated with the presence of carcinoma at lumpectomy. The results were analyzed with chi(2) statistic, with P <.05 indicative of significant difference. RESULTS: Surgical excision revealed carcinoma in 22 (21%) of 104 ADH lesions. The lowest incidences of carcinoma (each P <.02) were 16% (15 of 92) in patients with no personal history of breast carcinoma, 13% (nine of 67) when maximum lesion diameter was less than 10 mm, and 8% (three of 36) when 100% of the mammographic lesion was removed at stereotactic biopsy. CONCLUSION: No clinical, mammographic, or biopsy features alone or in combination could be used to define a substantial subset of probably benign lesions with a less than 2% chance of carcinoma at lumpectomy.     

Lobular carcinoma in situ or atypical lobular hyperplasia at core-needle biopsy: is excisional biopsy necessary?

PURPOSE: To retrospectively determine frequency of invasive cancer or ductal carcinoma in situ (DCIS) at excisional biopsy in women with atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) at percutaneous core-needle biopsy (CNB). MATERIALS AND METHODS: Review of results in 6,081 consecutive patients who underwent CNB at two institutions revealed that in 35 (0.58%), LCIS (n = 15) or ALH (n = 20) was the pathologic finding with highest risk. Patient age range was 41-84 years (mean, 59 years). Of 35 patients, 26 (74%) underwent excisional biopsy and nine (26%) underwent mammographic follow-up for longer than 2 years. Lesions with a pathologic upgrade were noted when invasive cancer or DCIS occurred at the CNB site. CNB results in patients with a diagnosis of atypical ductal hyperplasia (ADH) (75 of 6,081 [1.2%]) were reviewed; these patients underwent subsequent excisional biopsy. Statistical comparison of frequency of upgrading of lesions in patients with a diagnosis of LCIS or ALH at CNB and in those with a diagnosis of ADH at CNB was performed (Pearson chi(2) test). RESULTS: In six (17%) of 35 (95% CI: 4.7%, 29.6%) patients, lesions were upgraded to DCIS (n = 4) or invasive cancer (n = 2). In 15 patients with LCIS diagnosed at CNB, lesions in four (27%) were upgraded to either DCIS or invasive cancer. In 20 patients with ALH diagnosed at CNB, lesions were upgraded to DCIS in two (10%). Lesions in nine patients who underwent mammographic follow-up were stable. No mammographic or technical findings distinguished patients with upgraded lesions from those whose lesions were not upgraded. In 12 (16%) of 75 (95% CI: 7.7%, 24.3%) patients with ADH, lesions were upgraded. Difference between the upgrade rate in patients with LCIS or ALH and that in those with ADH was not significant (P =.88). CONCLUSION: Lesions in 17% of patients with LCIS or ALH at CNB were upgraded to invasive cancer or DCIS; this rate was similar to the upgrade rate in patients with ADH. Excisional biopsy is supported when LCIS, ALH, or ADH is diagnosed at CNB.     

Is it necessary to biopsy the obvious?

OBJECTIVE: The radiologist and oncologist are often confident that biopsy will confirm their suspicion of recurrent disease, but a biopsy is performed to confirm the histologic diagnosis before beginning or altering therapy. We have examined data to determine how often the biopsied lesion represents recurrent disease from the primary tumor or is an instance of new cancer, and whether recurrent disease can be predicted. MATERIALS AND METHODS: We reviewed the medical and imaging records of 253 patients who underwent CT-guided biopsy of an abdominal or pelvic lesion between 1993 and 1996. Sixty-nine of the 253 patients had a previously diagnosed primary tumor and were being examined for possible tumor recurrence or metastasis. The images of these 69 patients were analyzed to determine if the pattern of disease was typical of recurrence or metastasis. RESULTS: In 55 of the 69 patients, the pattern was judged to be typical of metastatic or recurrent disease. Biopsy confirmed this suspicion in all 55 patients. In 14 of the 69 patients, the pattern of spread was judged not to be typical of recurrence or metastasis. These 14 patients were found to have a new primary tumor (n = 4), benign processes (n = 2), and recurrences (n = 8). CONCLUSION: Of the patients for whom radiographic findings suggested recurrence, we found no patients in whom a new primary tumor would have been missed if biopsy had been avoided. Data should now be acquired prospectively to determine whether it may be prudent to make treatment decisions on the basis of imaging findings alone, without histologic confirmation.