Performance of breast lesion excision system (BLES) in complete removal of papillomas presented mammographically as groups of calcifications

ObjectivesTo retrospectively assess the stereotactic one-pass BLES performance in excision of small groups of calcifications seen on mammogram that proved to be papillomas.MethodsBetween January 2014 and January 2016, 37/400 cases (9.2%) of stereotactic BLES biopsies performed in our department due to suspicious calcifications proved to be papillomas. Lesions with atypia underwent surgical removal and lesions with no atypia were followed up for 2 years. BLES and surgical histology results, radiological removal and 2-years stability were statistically analysed to assess BLES performance in biopsy and excision of papillomas.ResultsThe mean mammographic size of papillomas was 6.54 mm (st dev = 3.85, range 2 mm−17 mm) and within the size excised by the BLES needle (20 mm). 4/37 cases (10.8%) showed atypia. BLES excision was achieved in 29/37 cases (78.4%); radiological removal based on post BLES mammogram was achieved in 25/29 cases (86.2%). In the remaining 8/37 cases the papillomas were seen at the ink of the specimens' margins; 3/8 cases showed residual calcifications on post-BLES mammogram. The BLES histology result of removal and the mammographic size of the papillomas were found to be statistically significant predictive factors of excision (p < 0,001, Fisher's exact test, Mann Whitney test). Follow up mammograms showed no change for a period of 2 years.ConclusionBLES is a safe and accurate technique to biopsy papillomas with high success rates of excision which could potentially minimize the need of subsequent radiological or surgical excision.     

Predictive factors for complete excision and underestimation of one-pass en bloc excision of non-palpable breast lesions with the Intact(®) breast lesion excision system

Objective

Image-guided percutaneous biopsy is the recommended initial diagnostic procedure for suspicious mammographic lesions. This study was conducted to determine the accuracy of the Intact^® breast lesion excision system (BLES) and to identify predictive factors for complete excision and underestimation.

Material and methods

A prospective study was conducted between January 28, 2008 and April 30, 2009 on 166 biopsy procedures using Intact^® biopsy device. Diagnoses obtained from biopsy specimen were compared with to final diagnosis on surgical excision specimen.

Results

Of the 166 patients, 15 (9%) displayed lesions with cell atypia, 28 (17%) had an intra ductal carcinoma (IDC) and 9 (5%) had an invasive carcinoma. Eight of 15 patients with cell atypia had open surgical excision, and none showed underestimation. All patients with IDC underwent surgical excision: we found an invasive carcinoma in 6 cases (21.4% underestimation) and a complete removal of the lesion by the Intact^® BLES in 11 cases (39%). All 9 patients with invasive carcinoma had a surgical excision, with 1 complete removal of the lesion by Intact^® BLES. Multivariate analyses did not identify predictive factors for underestimation; clear margins ≥1 mm on biopsy specimen was the only independent predictive factor of complete excision (OR = 8.51, p = 0.02).

Conclusions

Intact^® BLES provides a safe alternative to vacuum assisted core needle biopsy (VACNB) with an underestimation rate comparable to those previously reported for VACNB. The high rate of complete removal of the lesions, particularly ISC, offers an interesting perspective of avoiding subsequent excisional surgery for small lesions and thus requires further confirmational study.     

Management of non malignant papillary lesions diagnosed on percutaneous biopsy

PURPOSE: To assess the reliability of percutaneous breast biopsies in diagnosing and managing non malignant papillary lesions and determine if subsequent excision must be systematic. MATERIALS AND METHODS. Retrospective review of 2233 breast biopsies over a 43 months period (September 2001 to March 2005): sonographically guided core biopsies (n = 836), ultrasound (n = 346) or stereotactic (n:1051) guided vacuum biopsies. 86 non malignant papillary tumors were diagnosed (core biopsy:28, US:38 and stereotactic guided vacuum biopsy:20). A larger sample was systematic after core biopsy: lumpectomy (n = 19) or vacuum biopsy (n = 9). Surgical excision followed vacuum biopsy (n = 18) in case of atypia or sampling excision. Alternatively, yearly follow-up was advised (n = 40). Correlation with surgical findings (n = 37) or mammographic follow-up (n = 49) is presented. The influence of various factors on the risk of underestimation was analysed. RESULTS: Surgical resection revealed an underestimation of 5/37 (13.5%): 4/19 with core- and 1/18 with vacuum-assisted biopsy corresponding to 4 low grade ductal carcinoma in situ and a microinvasive ductal carcinoma in situ. It was higher for core biopsies and related to age and size: higher when women<50 years and when radiological image>1 cm. The influence of the other factors was not significant. Of the 9 non operated papillomas after core biopsy, vacuum biopsy revealed an additional underestimation (low-grade ductal carcinoma in situ). Of the 49 papillary lesions that were not surgically biopsied, 40 were monitored at 2-42 months (average: 19 months). No carcinoma was detected during this follow-up. CONCLUSION: Percutaneous biopsy is an accurate technique in managing papillary tumors. A larger histologic specimen is necessary after core biopsy. Vacuum biopsy is an attractive alternative to surgery for smaller papillomas (<1 cm), but in spite of nonsignificant results we advise subsequent excision in case of multiple papillomas, atypia or residual tumor.     

The breast lesion excision system (BLES) under stereotactic guidance cannot be used as a therapeutic tool in the excision of small areas of microcalcifications in the breast

ObjectiveThe breast lesion excision system (BLES) is a new, automatic percutaneous breast biopsy device that excises single large specimens using radiofrequency cutting. The aim of this study was to determine whether BLES, under stereotactic guidance, can be used as a therapeutic tool in the assessment of small areas of microcalcifications in the breast by providing samples with clear margins.Material and methodsIn this retrospective study, 149 patients with suspicious (BIRADS 4 or 5) small areas of microcalcifications underwent stereotactic-guided BLES. Of these, 34 patients (22.8%) with microcalcifications that had a diameter smaller than the basket size (≤15 mm) underwent both BLES and subsequent surgery. Histopathology findings from BLES and subsequent surgery were compared. Identical, underestimation and total excision findings were assessed.ResultsBLES revealed fourteen (41.1%) high-risk lesions, ten (29.4%) ductal carcinomas in situ, and ten (29.4%) invasive cancers. Identical results between BLES and surgery were seen in 17/34 (50%) lesions. Surgery confirmed total excision of BLES in 15/34 (44.1%) lesions. Underestimation was seen in 2/34 (5.8%) lesions.ConclusionBLES allows accurate diagnosis of small areas of microcalcifications, with few underestimates. BLES is a diagnostic, but cannot be considered to be a therapeutic tool in the case of suspicious microcalcifications because total excision was seen in only 44.1% of these lesions. Studies are needed to address the therapeutic benefit of this procedure in solid lesions.     

Predicting invasion in mammographically detected microcalcification

AIM: To identify pre-operative factors which predict presence of invasive disease within mammographically detected malignant microcalcification. MATERIALS AND METHODS: A retrospective analysis was undertaken of 116 serial stereotactic core needle biopsies (SCNBs) performed on malignant mammographic calcification. Final surgical pathology was correlated with pre-operative features (clinical, radiological and core histology) in an attempt to predict the presence of an invasive component. RESULTS: Thirty-eight clusters contained invasive carcinoma. The sensitivity of SCNB for invasion was 55%. Clinical features, calcium morphology and cluster size were not shown to be predictive of invasive disease. Ductal carcinoma in situ (DCIS) of high grade on core histology and increasing number of calcifications were predictive of increased risk of invasion (high grade core biopsy DCIS and > 40 calcifications 48% invasive at surgical histology; high grade core biopsy DCIS and < 40 calcifications 15% invasive; non-high grade core biopsy DCIS 0% invasive). CONCLUSIONS: Identification of those clusters diagnosed as DCIS by percutaneous biopsy which are likely to harbour an invasive component is possible. It would seem reasonable to consider staging the axilla at therapeutic surgery in these patients.     

Stereotactic core needle biopsy of nonpalpable breast lesions using a conventional mammography unit with an add-on device

OBJECTIVE: The purpose of this prospective study was to assess the accuracy of an add-on stereotactic unit for core needle biopsy of mammographic lesions. SUBJECTS AND METHODS. Between September 1994 and February 2001, 506 stereotactic core needle biopsies of mammographic lesions in 492 patients were performed in our center on a mammography unit with add-on stereotactic equipment. Of the initial 92 patients, 80 underwent stereotactic core needle biopsy and surgical excision simultaneously. In subsequent cases, surgical biopsy was performed after core biopsy in patients who had malignant or atypical histologic results or discordance between mammographic and pathologic findings. Follow-up mammography was advised for all patients whose core biopsy results were diagnosed as benign lesions. RESULTS: Histologic results for 506 lesions undergoing stereotactic core needle biopsy were as follows: 113 (22.3%) were malignant; 369 (72.9%), benign; and 24 (4.7%), atypical. Of 113 malignant lesions identified at stereotactic core needle biopsy, 111 were confirmed as malignant, whereas two showed no evidence of malignancy at surgical excision. Of 369 lesions diagnosed as benign at stereotactic core needle biopsy, 172 (46.6%) showed no change on follow-up mammography, 114 (30.9%) were lost to follow-up, and 83 (22%) underwent surgical excision. Of 24 lesions with atypical histology, 23 had surgical follow-up, six were malignant, nine were benign, and eight were confirmed as showing atypical histology. Stereotactic core needle biopsy of the 506 lesions was complicated by five (1.0%) cases of vasovagal attack and four (0.8%) cases of bleeding. The resulting sensitivity, specificity, and positive and negative predictive values were 98.3%, 93.0%, 86.0%, and 99.2% respectively. CONCLUSION: Biopsy with an add-on unit is safe, reliable, accurate, and cost-effective with results comparable to those reported for dedicated prone biopsy devices.     

B3 breast lesions determined by vacuum-assisted biopsy: how to reduce the frequency of benign excision biopsies

Purpose

The aim of this study was to identify parameters allowing differentiation among the diverse group of B3 lesion at stereotactic vacuum-assisted biopsy (VAB) to identify patients with a low risk of cancer and who can therefore be referred for follow-up rather than surgery and thus reduce the number of unnecessary surgical procedures.

Materials and methods

Among 608 VAB procedures performed for nonpalpable ultrasound (US)-occult mammographic abnormality, 102 cases of B3 were included in this study. Mammographic lesion type, lesion size, Breast Imaging Reporting and Data System (BIRADS) category, number of specimens per lesion and presence of atypia were retrospectively analysed. Results were compared with histological findings at surgery (53 cases) or mammographic findings during follow-up (49 cases). Statistical analysis was performed with univariate analysis (chi-square test), and statistical significance was set at p<0.05.

Results

The majority of cases were depicted as isolated microcalcifications (82.3%), were smaller than 10 mm (80.4%), had a low level of radiological suspicion (64.7%) and had 11 or more cores sampled (94.1%). Atypia at VAB was reported in 60 of 102 cases (58.8%). Carcinoma was found at excision in 5/60 (8%) B3 lesions with atypia and in no B3 lesions without atypia (p=0.146). Cancer at surgery was more frequent among cases of isolated microcalcifications (p=0.645), cases with high radiological suspicion (p=0.040) and those with a smaller number of cores sampled (borderline significant p=0.064).

Conclusions

On the basis of our experience, the presence or absence of atypia in our series proved to be the reliable criterion to prompt or avoid surgery in cases with a VAB finding of B3 lesion. This criterion may therefore be adopted in practice to more accurately select patients for surgery.     

Clinical,imaging, and intervention factors associated with the upgrade of isolated flat epithelial atypia

PurposeThis study aims to determine clinical, imaging, and intervention factors associated with the upgrade of flat epithelial atypia (FEA) diagnosed on vacuum-assisted biopsy (VAB) in order to formulate criteria for excision and better assist in management.MethodsBetween 2012 and 2015, 254 patients had a form of atypia diagnosed on ultrasound, MRI or stereotactic VAB and met eligibility for this study. Demographic, imaging, biopsy and pathology characteristics were analyzed for association with upgrade. We compared isolated FEA to all of the atypias grouped together.ResultsOf the 254 atypia lesions, 72 (28%) were isolated FEA, and the upgrade rate was 2.8% (2/72). Statistically significant factors present with upgrade of isolated FEA include personal history of breast cancer and cancer diagnosis on a concurrent separate core biopsy. Other factors associated with upgrade include first degree family history of breast cancer, segmental calcification distribution, extent of calcifications >2 cm, and <25% of calcifications removed on biopsy.ConclusionIn patients with biopsy results of isolated FEA, in the absence of personal or first degree family history of breast cancer, cancer on a concurrent biopsy, segmental calcification distribution, extent of calcifications >2 cm, and only 0–24% calcifications removed on biopsy, patients may be safely followed with imaging, avoiding unnecessary excision.     

Vacuum-assisted biopsy diagnosis of atypical ductal hyperplasia and patient management

Purpose

This study sought to evaluate the accuracy of vacuum-assisted biopsy (VAB) in the diagnosis of atypical ductal hyperplasia (ADH) by determining the rate of VAB underestimation compared with definitive histology. In addition, an attempt was made to identify parameters that could help determine the most appropriate patient management.

Materials and methods

We retrospectively reviewed 1,776 VAB procedures performed between November 1999 and January 2008 for suspicious subclinical breast lesions visible only at mammography. A total of 177 patients with a VAB diagnosis of pure ADH were studied. Patients with a diagnosis of ADH associated with other lesions (lobular intraepithelial neoplasia, papilloma), atypical lobular hyperplasia, lobular carcinoma in situ and any lesions with a microhistological diagnosis other than ADH were excluded. Mammographic appearance of lesions was as follows: 152 mostly clustered microcalcifications (86%); five opacities with microcalcifications (3%); 12 single opacities (3%); and eight parenchymal distortions (4%), of which five were without and three were with microcalcifications. In cases underestimated by VAB, we evaluated the extent of ADH within ducts and lobules. Based on results, patients were subdivided into two groups: ??2 ADH foci; >2 ADH foci. Patients were subdivided into two groups: one was referred for surgery and the other for follow-up care. The decision to either perform or not perform surgery was based on combined analysis of the following parameters: patient age; risk factors in the patient??s history; mammographic extent of microcalcifications; complete excision of microcalcifications at VAB; and final Breast Imaging Reporting and Data System (BI-RADS) assessment.

Results

In the first group (n=98), comparison of microhistology with final histology revealed that 19 cases of ADH had been underestimated by VAB. In the second group (n=79), six cases of ADH showed progression of the mammographic abnormality, which was subsequently confirmed by surgical biopsy.

Conclusions

The most relevant parameters affecting the decision to proceed to surgical excision were lesion diameter >7 mm on mammography, >2 ADH foci, incomplete removal of the calcifications and a family and/or personal history of breast cancer. Although there are no definite mammographic predictors of malignancy, a radiological assessment of suspicious lesion in the presence of an additional equivocal parameter always warrants surgical management.     

Stereotactic 11-gauge vacuum-assisted breast biopsy: a validation study

OBJECTIVE: The aim of our study was to determine the false-negative rate of stereotactic 11-gauge vacuum-assisted biopsy in a validation study of lesions that had subsequent surgical excision. MATERIALS AND METHODS: Retrospective review was performed of 318 lesions that underwent stereotactic 11-gauge vacuum-assisted biopsy and subsequent surgical excision. A false-negative case was defined as a pathologically proven cancer in which stereotactic biopsy yielded benign results without atypia. Medical records, imaging studies, and histologic findings were reviewed. RESULTS: False-negative findings were encountered at stereotactic 11-gauge vacuum-assisted biopsy in 3.3% (7/214) of pathologically proven cancers. False-negative findings occurred in 3.5% (4/115) of malignant calcification lesions versus 3.0% (3/99) of malignant masses (p = 1.0). The seven false-negative findings included five Breast Imaging Reporting and Data System (BI-RADS) category 5 lesions that yielded benign results at biopsy, one BI-RADS category 4 mass that benign breast tissue, and one BI-RADS category 4 cluster of calcifications in which no calcifications were retrieved. The false-negative rate was 10.0% (6/60) for radiologists who performed 15 or fewer previous stereotactic vacuum-assisted biopsy procedures versus 0.6% (1/154) for radiologists who performed more than 15 previous stereotactic vacuum-assisted biopsy procedures (p = 0.002). CONCLUSION: Stereotactic 11-gauge vacuum-assisted biopsy had a false-negative rate of 3.3% that diminished to 0.6% with experience. All false-negative findings could be prospectively identified because of failure to sample calcifications or imaging-histologic discordance.     

Radial sclerosing lesions of the breast: mammographic and pathologic correlation.

OBJECTIVE: The purpose of this study was to define the mammographic appearance of 96 pathologically proven radial sclerosing lesions (RSLs) and to determine the frequency of association with malignancy in and around the lesions. METHODS: Ninety-three patients with 96 RSLs were identified from the pathology files of the BC Cancer Agency, and the reasons for biopsy were obtained. All preoperative mammograms were reviewed, and the RSLs were categorized as classic (typical), non-classic (atypical), or incidental. The histopathologic results were retrospectively examined for atypia, ductal carcinoma in situ (DCIS) and invasive carcinoma. RESULTS: In 67 of the 96 biopsies, the RSL was the primary mammographic abnormality that led to biopsy. In this group, 17 cases (25.4%) contained atypia, 17 (25.4%) DCIS, and 4 (6%) invasive carcinoma. Nineteen of these RSLs presented as mass-like opacities that mimicked carcinoma. No single mammographic feature consistently predicted premalignant or malignant lesions. In the remaining 29 patients, biopsy was carried out because of pleomorphic calcifications or masses, and RSLs were found incidentally in specimens. These specimens included 4 cases (13.8%) of atypia, and 1 case (3.4%) of DCIS. CONCLUSION: Of the 67 mammographically detected RSLs, only 48 (71.6%) had a typical mammographic appearance. We found a significant amount of atypia (25.4%) and malignancy (25.4% DCIS and 6% invasive carcinoma) in mammographically detected RSLs. Because of the lack of predictable radiological features, adequate open surgical biopsy is recommended for all focal abnormalities in which a RSL is a possible diagnosis.     

Mammographic control after quadrantectomy and radiation therapy]

The efficacy of combined surgery and radiation therapy in the treatment of breast cancer has increased the use of mammography in the follow-up to detect early recurrences. The authors report their experience in the follow-up of 43 breast cancers after treatment with local excision, axillary dissection, and irradiation. Mammography was performed at 6.12, and 24 months. The radiological findings were: 38/43 (88.3%) breasts with abnormal mammographic patterns, skin thickening in 36/43 (83.7%) cases, breast retraction in 16/43 (37.2%), architectural distortion in 17/43 (39.5%), increased parenchymal density in 33/43 (76.7%), calcifications in 6/43 (13.9%), and a mass in 10/43 (23.2%) cases. The authors describe histologic changes, corresponding to mammographic findings, and evolution of the treated breasts. Suspicious findings were microcalcifications in one case and a mass in 6 cases (4 of them at 6 months and 2 at 12). Excisional biopsy, performed in the above 7 patients, confirmed recurrence in 4 cases. In 3 cases with negative pathology, where the malignant nature of the lesion could not be demonstrated, we observed: a cluster of microcalcifications undistinguishable from neoplasm in 1 case and spiculated nodules with architectural distortion in the extant 2 cases. Further limitations of mammography were due to radiological density of the breast in one case, and to its minimal size in another--these elements delayed both correct interpretation of mammographic findings and final diagnosis. The low agreement between mammography and histology proved the difficulty of both analysis and evaluation of abnormal post-irradiation breast tissue. The authors, in agreement with literature reports, suggest the schedule for clinical and mammographic follow-up.     

Post-lumpectomy breast calcifications: Can original tumor features assist in determining need for biopsy?

ObjectiveThe objective of our study was to determine whether, in the digital era, imaging features of a primary breast tumor can be used to influence the decision to biopsy ipsilateral breast calcifications that occur following surgery in women treated with breast conservation surgery (BCS).Materials and methodsWe retrospectively identified women treated with BCS who subsequently developed suspicious calcifications in the treated breast (BI-RADS 4 or 5) from January 2012 – December 2018. Only cases with histopathological diagnosis by stereotactic or surgical biopsy were included. Pathology reports were reviewed, and biopsy results were considered malignant if invasive carcinoma or ductal carcinoma in situ (DCIS) was found. All other results were considered benign.Fisher's exact test was done comparing frequencies of malignancy between those patients whose original tumor had calcifications versus those whose original tumors were not calcified.ResultsOf 90 women with suspicious calcifications on a post-BCS mammogram, 65 (72.2%) were biopsy proven benign and 25 (27.8%) were malignant. The original tumor presented without calcifications in 39 patients (43%), and 51 (57%) had calcifications with or without associated mass, focal asymmetry, or architectural distortion. New calcifications were less likely to be malignant if the original tumor presented without calcifications (5/39; 12.8%) as compared to original tumors with calcifications (20/51; 38.5%) [p-value < 0.05].ConclusionNew calcifications after BCS are significantly less likely to be malignant if the original tumor presented without calcifications. However, with a PPV of 12.8%, even calcifications in a patient with a non-calcified primary tumor require biopsy.     

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.     

A comparison of 14 and 12 gauge needles for core biopsy of suspicious mammographic calcification

This study was carried out to compare the efficacy of 14 vs 12 G needles in stereotactic core biopsy of mammographic calcification. A consecutive series of 100 impalpable mammographic calcifications, without an associated mass and requiring stereotactic core biopsy were randomly allocated to either 14 G or 12 G needle sampling. All biopsies were performed using an upright stereotactic digital unit (Senovision GE) and a Bard automated biopsy gun. Core biopsy results were categorized as either normal, benign, atypical ductal hyperplasia, suspicious of ductal carcinoma in situ (DCIS), DCIS or invasive cancer. The radiographic calcification retrieval rates, complete and absolute sensitivity for malignancy of DCIS and DCIS with an invasive focus were obtained by comparison of core results with surgical histology. Radiographic calcification retrieval was achieved in 86% when using 14 G and 12 G needles. The absolute sensitivity and complete sensitivity for diagnosing DCIS were the same with 12 G and 14 G needles (72% versus 71% and 93% versus 94%, respectively). The use of 12 G needles does not appear to confer benefit over the use of 14 G needles in the diagnosis of mammographic calcification.     

Mammographic predictors of the presence and size of invasive carcinomas associated with malignant microcalcification lesions without a mass

OBJECTIVE: Our objective was to determine the degree with which mammographic features predict the presence and size of invasive carcinomas associated with malignant mammographic microcalcification lesions without a mass. MATERIALS AND METHODS: Mammographic features were correlated with pathologic features in 304 consecutive breast carcinomas manifested by mammographic calcifications only in a prospective evaluation. RESULTS: Mammographic calcifications associated with breast carcinoma had the final pathologic diagnoses of pure ductal carcinoma in situ (DCIS) in 65% of patients, DCIS with a focus of invasion in 32%, and invasive carcinoma only in 4%. Invasive foci were more likely associated with mammographic calcification size of 11 mm and greater (40%, 77/194) compared with 1-10 mm (26%, 29/110; p = 0.019). Invasive foci were also more likely associated with linear calcifications (44%, 55/126) compared with granular calcifications (29%, 51/178; p = 0.007). The frequency of invasion did not increase with calcification extents greater than 10 mm. The frequency of invasion ranged from 22% for less than or equal to 5-mm granular calcifications to 45% for linear calcifications of 11 mm and greater. Only 11% of cancers characterized by fine granular calcifications were associated with invasion as compared with 32% of those with coarse and mixed granular calcifications (p = 0.002). CONCLUSION: Mammographic calcification features of malignant lesions cannot predict the absence of invasion with greater than 90% predictive value or predict the presence of invasion with greater than 45% predictive value. Increased extent of calcifications greater than 10 mm was not associated with greater likelihood of invasion.     

Underestimation of the presence of breast carcinoma in papillary lesions initially diagnosed at core-needle biopsy

PURPOSE: To retrospectively determine the degree of underestimation of breast carcinoma diagnosis in papillary lesions initially diagnosed at core-needle biopsy. MATERIALS AND METHODS: Institutional review board approval and waiver of informed consent were obtained for this HIPAA-compliant study. Mammographic database review (1994-2003) revealed core biopsy diagnoses of benign papilloma (n=38), atypical papilloma (n=15), sclerotic papilloma (n=6), and micropapilloma (n=4) in 57 women (mean age, 57 years). Excisional or mammographic follow-up (>or=2 years) findings were available. Patients with in situ or invasive cancer in the same breast or patients without follow-up were excluded. Findings were collected from mammography, ultrasonography, core technique, core biopsy, excision, and subsequent mammography. Reference standard was excisional findings or follow-up mammogram with no change at 2 years. Associations were examined with regression methods. RESULTS: In 38 of 63 lesions, surgical excision was performed; in 25 additional lesions (considered benign), follow-up mammography (24-month minimum) was performed, with no interval change. In 15 lesions, 14-gauge core needle was used; in 48, vacuum assistance (mean cores per lesion, 8.7). Carcinoma was found at excision in 14 of 38 lesions. Core pathologic findings associated with malignancy were benign papilloma (n=1), sclerotic papilloma (n=1), micropapilloma (n=2), and atypical papilloma (n=10). Frequency of malignancy was one (3%) of 38 benign papillomas, 10 (67%) of 15 atypical papillomas, two (50%) of four micropapillomas, and one (17%) of six sclerotic papillomas. Excisional findings included lobular carcinoma in situ (n=2), ductal carcinoma in situ (n=7), papillary carcinoma (n=2), and invasive ductal carcinoma (n=3). Low-risk group (micropapillomas and sclerotic and benign papillomas) was compared with high-risk atypical papilloma group. Core findings were associated with malignancy at excision for atypical papilloma (P=.006). Lesion location, mammographic finding, core number, or needle type were not associated (P>.05) with underestimation of malignancy at excision. CONCLUSION: Benign papilloma diagnosed at core biopsy is infrequently (3%) associated with malignancy; mammographic follow-up is reasonable. Because of the high association with malignancy (67%), diagnosis of atypical papilloma at core biopsy should prompt excision for definitive diagnosis.     

The Swedish Two-County Trial twenty years later. Updated mortality results and new insights from long-term follow-up

The benefit of invitation to mammographic screening observed in this trial is maintained as a highly significant 32% reduction in breast cancer mortality. Mammographic screening for breast cancer continues to save lives after up to 20 years. Screening derives this benefit by improving the distribution of tumors diagnosed with respect to prognostic categories based on node status, size, and histology of tumors. There is potential for modern screening programs with shorter interscreening intervals to achieve even greater improvements in prognostic category and greater reductions in breast cancer mortality. Mammography can discriminate a subpopulation of high-risk cases, those displaying casting-type calcifications on the mammogram, among very small tumors, with fundamental implications for diagnosis and treatment.     

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%.     

Complications of percutaneous stereotactic vacuum assisted breast biopsy system utilizing radio frequency

Objective

The Breast Lesion Excision System (BLES) is a novel, automatic breast biopsy device that utilizes radiofrequency to excise suspicious non-palpable mammographic lesions. The purpose of the present prospective study is to report and evaluate the complications of this new technique.

Materials and methods

In a two year period, we used the BLES device in 132 consecutive patients (134 procedures) with non-palpable mammographic lesions. The inclusion criteria consisted of suspicious microcalcifications, solid lesions and asymmetric density. In order to retrieve an intact biopsy specimen, we used the 12 mm, 15 mm or 20 mm tissue basket under local anesthesia, depending on the size of the lesion. Complications were recorded and classified as immediate if occurring during or shortly after the procedure, or late, if occurring in the post-procedure days.

Results

The procedure was considered successful in all cases, with mammographic confirmation of appropriate excision of the targeted lesion. Although, in a single case the basket initially failed to deploy. Immediate complications were encountered in 11 patients, with minor hemorrhage being the most common (n = 6). 17 patients suffered late complications, in seven of whom delayed wound healing was observed. Overall, 27 patients suffered Grade 1 complications (20.14%), one patient experienced a Grade 2 complication while no patients encountered Grade 3–5 complications.

Conclusions

According to our experience, the BLES device is an efficient and safe breast biopsy method, with low complication rates, which are minor in their majority. It appears to be a very promising alternative to other, minimally invasive, breast biopsy techniques.