Malignancy rates of stereotactic biopsies of two or more distinct sites of suspicious calcifications in women without known breast cancer

ObjectiveTo determine the malignancy rate in women without a concurrent breast cancer diagnosis at presentation who underwent stereotactic biopsies of distinct sites of suspicious calcifications.MethodsThis retrospective study included 280 women without a concurrent breast cancer diagnosis who underwent 587 stereotactic biopsies of two or more distinct sites of suspicious calcifications in one or both breasts at our institution from 2010 to 2015.ResultsThe overall malignancy rate was 27.9% (78/280, 95% CI, 22.7%–33.5%) at the patient level and 18.7% (110/587, 95% CI, 15.7%–22.1%) at the lesion level. Eighteen had invasive cancers (mean [range] diameter, 0.5 cm [0.1–1.7]; six grade I, ten grade II, two grade III), one of whom had multifocal and another bilateral malignancy. Sixty had ductal carcinoma in situ. Of the 171 with all calcifications of the same morphology, 139 (81.3%) had all calcifications in the same pathology category (benign, high-risk, or malignant).ConclusionThe malignancy rate is substantial in women who undergo stereotactic biopsies of two or more distinct calcification sites. Given the nearly 20% rate of dissimilar histopathology between calcification sites with similar morphology, if only one site is biopsied and results in a malignant pathology, biopsy of the additional calcifications is warranted. Even if the pathology result of the one site biopsy is benign, biopsy of additional sites may perhaps still be necessary.     

Malignancy rates of stereotactic biopsies of two or more distinct sites of suspicious calcifications in women without known breast cancer

ObjectiveTo determine the malignancy rate in women without a concurrent breast cancer diagnosis at presentation who underwent stereotactic biopsies of distinct sites of suspicious calcifications.MethodsThis retrospective study included 280 women without a concurrent breast cancer diagnosis who underwent 587 stereotactic biopsies of two or more distinct sites of suspicious calcifications in one or both breasts at our institution from 2010 to 2015.ResultsThe overall malignancy rate was 27.9% (78/280, 95% CI, 22.7%–33.5%) at the patient level and 18.7% (110/587, 95% CI, 15.7%–22.1%) at the lesion level. Eighteen had invasive cancers (mean [range] diameter, 0.5 cm [0.1–1.7]; six grade I, ten grade II, two grade III), one of whom had multifocal and another bilateral malignancy. Sixty had ductal carcinoma in situ. Of the 171 with all calcifications of the same morphology, 139 (81.3%) had all calcifications in the same pathology category (benign, high-risk, or malignant).ConclusionThe malignancy rate is substantial in women who undergo stereotactic biopsies of two or more distinct calcification sites. Given the nearly 20% rate of dissimilar histopathology between calcification sites with similar morphology, if only one site is biopsied and results in a malignant pathology, biopsy of the additional calcifications is warranted. Even if the pathology result of the one site biopsy is benign, biopsy of additional sites may perhaps still be necessary.     

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.     

Stereotactic vacuum-assisted breast biopsy: results, follow-up and correlation with radiological suspicion

PURPOSE: The purpose of this study was to assess the accuracy and clinical usefulness of stereotactic vacuum-assisted biopsy (VAB) for diagnosing suspicious, nonpalpable, only mammographically detectable breast lesions. MATERIALS AND METHODS: We retrospectively evaluated the results of percutaneous stereotactic VAB with 11-gauge needles performed over a period of 34 months on 228 nonpalpable suspicious breast lesions detectable on mammography only [Breast Imaging Reporting and Data System (BI-RADS) 3: 25.9%; BI-RADS 4: 67.1%; BI-RADS 5: 7%]. The imaging histological concordance was ascertained for each lesion. In cases of discordance, repeat biopsy or surgical excision were recommended; in cases of benign lesions, we urged a follow-up of at least 6 months and for borderline and malignant lesions a surgical excision. We also evaluated concordance between VAB results and subsequent examinations (surgical excision or followup). RESULTS: VAB demonstrated 123 (54%) benign lesions (with six cases of imaging-histological discordance), 26 (11.4%) borderline lesions and 79 (34.6%) malignant lesions. We obtained a suitable post-VAB mammographic or histological evaluation for 78 benign lesions, 17 borderline lesions and 76 malignant lesions, with one (1.3%) false negative (FN) case, two (11.8%) underestimations of borderline lesions, 14 (18.4%) underestimations of malignant lesions and no (0%) false positive cases. We did not observe any postbiopsy complications or scars. CONCLUSIONS: Percutaneous histological VAB with an 11-gauge needle proved to be, as reported in previous studies, a reliable method for diagnosing nonpalpable, mammographically detectable only breast lesions, with an underestimation rate lower than core biopsy and a FN rate similar to that of surgical biopsy, without any significant complications.     

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.     

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.     

Enlarging biopsy-proven fibroadenoma: Is surgical excision necessary?

PurposeCore biopsy-proven fibroadenomas that enlarge on clinical or imaging follow-up are often surgically excised to exclude an associated malignancy. The purpose of this study was to assess how often malignancy is detected upon excision, and to determine whether excision of enlarging, biopsy-proven, uncomplicated fibroadenomas is still warranted.Materials and methodsReview of our institutional pathology database from 2000 to 2010 identified 1117 cases of fibroadenoma, and retrospective chart review, including review of pathology and imaging findings of all these records, was performed.Results1117 cases of fibroadenoma were identified in a population of women ranging from ages 17 to 78. Of these, 378 (33.8%) were diagnosed by ultrasound core needle biopsy and formed the study population. Of the 378 cases, 24 (6.3%) had co-existent atypia and were immediately excised; these cases were excluded. An additional 107 (28%) were lost to follow-up. Of the remaining 247 cases, 201 (81%) showed stability on follow-up imaging (mean 31.5 months), and 46 (18.6%) enlarged on follow-up. Of the 46 biopsy proven fibroadenomas that enlarged, 19 had a biopsy at initial presentation and 27 underwent biopsy after they enlarged. Seventeen of the 19 were excised after enlargement, and pathology confirmed fibroadenoma in all cases (100%); two enlarged on initial follow-up imaging but remained stable for at least three years on continued follow-up. Of the 27 cases which were biopsied after enlargement, 23 revealed fibroadenoma on core biopsy, 3 had fibroadenoma with associated atypia with subsequent surgery revealing fibroadenoma and no associated malignancy, and one showed fibroadenoma with smooth muscle with subsequent surgery showing phyllodes tumor.ConclusionBased on this study, enlarging biopsy proven fibroadenomas are not associated with malignancy; therefore, surgical excision does not seem warranted. For presumed enlarging fibroadenomas on imaging, core biopsy should be performed to exclude associated atypia or phyllodes tumor. Finally, surgical excision is indicated for lesions with associated atypia or suspected phyllodes and for symptomatic lesions or cosmetic reasons.     

Breast masses: removal of all US evidence during biopsy by using a handheld vacuum-assisted device--initial experience

PURPOSE: To assess the effects of removal of all ultrasonographic (US) evidence of breast lesions by using a vacuum-assisted biopsy (VAB) device. MATERIALS AND METHODS: Thirty-four women with breast masses underwent US-guided biopsy with an 11-gauge VAB device, with which removal of all evidence of the lesion was attempted. Histologic findings were compared with results of surgery and follow-up imaging. Patient tolerance and perceptions of the procedure and the ability of the procedure to eliminate a palpable finding were evaluated with questionnaires and findings at follow-up physical examination. RESULTS: The biopsy protocol was completed in all cases. Twenty-six benign lesions (76%) and eight malignancies (24%) were diagnosed. After VAB, 10 patients (29%) underwent surgery on the basis of histologic findings of invasive carcinoma (n = 7), ductal carcinoma in situ (n = 1), lobular neoplasia (n = 1), or atypical ductal hyperplasia (n = 1). VAB resulted in complete excision of four of 10 lesions: two of eight malignancies and two of two benign lesions. Among 21 patients with benign lesions who underwent 6-month follow-up imaging, eight (38%) had a definite residual mass. At 6-month follow-up examination, VAB was seen to have eliminated the palpable abnormality in seven (88%) of eight patients with initially palpable benign masses. Thirty-two patients (94%) described no or mild pain during biopsy, and 33 patients (97%) rated care as excellent. CONCLUSION: After removal of all US evidence of breast masses with a VAB device, there was a substantial probability that residual lesion that was not visualized during the procedure would later be found at surgery or follow-up imaging. A palpable mass (< or =1.2 cm in mean diameter) was eliminated in 88% of cases, and patient tolerance and perceptions of the procedure were favorable.     

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation

Purpose

The aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy.

Materials and methods

In 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions.

Results

Technical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n=1) requiring no further therapeutic intervention, no complications occurred.

Conclusions

MRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.     

Lobular neoplasia detected at MRI-guided biopsy: imaging findings and outcomes

ObjectiveTo review MRI findings of pure lobular neoplasia (LN) on MRI guided biopsy, evaluate surgical and clinical outcomes, and assess imaging findings predictive of upgrade to malignancy.MethodsHIPAA compliant, IRB-approved retrospective review of our MRI-guided breast biopsy database from October 2008–January 2015. Biopsies yielding atypical lobular hyperplasia or lobular carcinoma in situ were included in the analysis; all biopsy slides were reviewed by a dedicated breast pathologist. Imaging indications, MRI findings, and histopathology were reviewed. Statistical analysis was performed using the two-tailed Fisher exact-test and the t-test, and 95% CIs were determined. A p < 0.05 was considered statistically significant.ResultsDatabase search yielded 943 biopsies in 785 patients of which 65/943 (6.9%) reported LN as the highest risk pathologic lesion. Of 65 cases, 32 were found to have LN as the dominant finding on pathology and constituted the study population. All 32 findings were mammographically and sonographically occult. Three of 32 (9.3%) cases of lobular neoplasia were upgraded to malignancy, all LCIS (one pleomorphic and two classical). The most common MRI finding was focal, heterogenous non-mass enhancement with low T2 signal. No clinical features or imaging findings were predictive of upgrade to malignancy.ConclusionIncidence of pure lobular neoplasia on MRI guided biopsy is low, with comparatively low incidence of upgrade to malignancy. No imaging or clinical features are predictive of upgrade on surgical excision, therefore, prudent radiologic-pathologic correlation is necessary.     

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.     

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.     

Stereotactic and sonographic large-core biopsy of nonpalpable breast lesions: results of the Radiologic Diagnostic Oncology Group V study

RATIONALE AND OBJECTIVES: To determine the diagnostic accuracy of stereotactically and sonographically guided core biopsy (CB) for the diagnosis of nonpalpable breast lesions. MATERIALS AND METHODS: Twenty-two institutions enrolled 2,403 women who underwent imaging-guided fine needle aspiration followed by imaging-guided large-CB of nonpalpable breast abnormalities. All mammograms were reviewed for study eligibility by one of two breast imaging radiologists. The protocol for image-guided biopsy, using either ultrasound (USCB) or stereotactic (SCB) guidance, was standardized at all institutions and all biopsy specimens were over-read by one of three expert pathologists. Patients with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, or lobular neoplasia on CB underwent surgical excision. Those with negative CB but suspicious ("discordant") pre-biopsy mammography also underwent surgical excision. Patients having a negative CB that was concordant with the pre-biopsy mammography suspicion were assigned to follow-up mammography at 6, 12, and 24 months following CB. RESULTS: A gold standard diagnosis based on definitive histopathologic diagnosis, mammography follow-up, or an imputed gold standard diagnosis was established for 1,681 patients. Of 310 cases with a gold standard diagnosis of invasive breast carcinoma, 261 (84.2%) were invasive carcinoma, 31 (10%) were ductal carcinoma in situ (DCIS), four (1.3%) were ADH, one (0.3%) was a non-breast cancer, and 13 (4.2%) were benign on CB. For 138 cases with a gold standard diagnosis of DCIS, 113 (81.9%) were DCIS, 20 (14.5%) were ADH, and five (3.6%) were benign on CB. For 57 cases (13 masses, 44 calcifications) with an initial CB diagnosis of ADH, atypical lobular hyperplasia or lobular neoplasia, 20 (35.1%) had a gold standard diagnosis of DCIS (4 masses, 16 calcifications) and four (7.0%) had a gold standard diagnosis of invasive cancer (4 calcifications). Of 144 cases (22 masses, 122 calcifications) with an initial CB diagnosis of DCIS, 31 (21.5%) had a gold standard diagnosis of invasive cancer (10 masses, 21 calcifications). The sensitivity, specificity and accuracy for CB by either imaging guidance method in this trial were .91, 1.00, and .98, respectively. The sensitivity, predictive value negative, and accuracy of CB for diagnosing masses (.96, .99, and .99, respectively) were significantly greater (P < .001) than for calcifications (.84, .94, and .96, respectively). The sensitivity (.89) of SCB for diagnosing all lesions was significantly lower (P = 0.029) than that of USCB (.97) because of the preponderance of calcifications biopsied by SCB versus USCB. There was no difference between USCB and SCB in sensitivity, predictive value negative, or accuracy for the diagnosis of masses (97.3, 98.9, and 99.2, respectively for USCB; 95.6, 98.5, and 98.9 respectively for SCB). CONCLUSION: Percutaneous, imaged-guided core breast biopsy is an accurate diagnostic alternative to surgical biopsy in women with mammographically detected suspicious breast lesions.     

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.     

基于BI-RADS评估伴或不伴点状/圆形钙化的可疑恶性钙化分类研究

目的 基于第5版乳腺影像报告与数据系统（BI-RADS）,探讨各钙化分布中伴或不伴点状/圆形钙化的各种可疑钙化的分类。方法 回顾性分析经乳腺X线摄影检出可疑钙化或点状/圆形钙化并有病理活检结果的女性病人289例,平均（47.2±9.4）岁。将可疑钙化根据是否伴有点状/圆形钙化分为2组,即单纯可疑钙化（不伴有）组和混合可疑钙化（伴有）组。对处于不同钙化分布及形态下的2组可疑钙化的阳性预测值（PPV）及BI-RADS分类进行分析。2组钙化间PPV比较采用χ²检验或Fisher确切概率检验,2组钙化间恶性风险比较以优势比（OR）和95%可信区间（CI）表示。结果 35处点状/圆形钙化均为良性,为BI-RADS 2类。可疑钙化共254处,其中混合可疑钙化104处,单纯可疑钙化150处。混合可疑钙化在区域性、成簇、线样和段样分布中的PPV均低于单纯可疑钙化（均P<0.05）,且恶性风险也低于单纯可疑钙化（均OR<1.0）。区域性、成簇及段样分布中,混合细小多形性钙化的PPV均低于单纯细小多形性钙化（均P<0.05）,且恶性风险也均较单纯细小多形性钙化更低（均OR<1.0）。区域性分布中,混合及单纯无定形钙化均为BI-RADS 4A类;成簇分布和段样分布中,混合及单纯无定形钙化均为BI-RADS 4B类。区域性、成簇、段样分布中混合及单纯细小多形性钙化均为BI-RADS 4B类及4C类。结论 依据BI-RADS,更细化分析点状/圆形钙化对各钙化分布中各种可疑钙化的影响,对精准评估可疑钙化恶性风险具有更大帮助。     

Impact of Second-Opinion Interpretation of Breast Imaging Studies in Patients Not Currently Diagnosed With Breast Cancer

PurposeTo study the impact of second-opinion interpretation of breast imaging studies submitted from outside facilities to a tertiary cancer center.Materials and MethodsA retrospective database review was conducted of second-opinion interpretations rendered at our institution from January 1, 2010, to June 30, 2014, on studies from patients who did not have a concurrent breast cancer diagnosis. A total of 2,253 patients were included.ResultsIn 800 of 2,253 patients (35.5%), the BI-RADS categories assigned at our institution and at outside facilities were discordant. Of 973 patients assigned BI-RADS category 4 or 5 at outside facilities, 278 (28.6%) were assigned BI-RADS category 1 to 3 (no biopsy necessary) at our institution. Of 923 patients assigned BI-RADS category 1 to 3 at outside facilities, 191 (20.7%) were assigned BI-RADS category 4 or 5 at our institution, and 189 of these had biopsies, which revealed 23 cancers, 15 high-risk lesions, and 151 benign lesions. One high-risk lesion at core biopsy was upgraded to invasive ductal carcinoma and ductal carcinoma in situ (DCIS) on excision, resulting in 24 cancers. Of these, 18 reflected true additional breast cancers detected as a result of second-opinion interpretation: 12 invasive carcinomas and 6 cases of DCIS. These results translate into a 9.4% (18/191) positive predictive value for the number of cancers diagnosed among all biopsies recommended and a 9.5% (18/189) positive predictive value for the number of cancers diagnosed among all biopsies recommended and actually performed.ConclusionsThese findings demonstrate the positive clinical impact of second-opinion interpretation at a tertiary cancer center of outside-facility breast imaging studies in patients without a breast cancer diagnosis.     

Cancelled stereotactic biopsy of calcifications not seen using the stereotactic technique: do we still need to biopsy?

Objective

To determine the frequency of cancelled stereotactic biopsy due to non-visualisation of calcifications, and assess associated features and outcome data.

Methods

A retrospective review was performed on 1,874 patients scheduled for stereotactic-guided breast biopsy from 2009 to 2011. Medical records and imaging studies were reviewed.

Results

Of 1,874 stereotactic biopsies, 76 (4 %) were cancelled because of non-visualisation of calcifications. Prompt histological confirmation was obtained in 42/76 (55 %). In 28/76 (37 %) follow-up mammography was performed, and 7/28 subsequently underwent biopsy. Of 27 without biopsy, 21 (78 %) had follow-up. Nine cancers (9/49, 18 %) were found: 6 ductal carcinoma in situ (DCIS), 3 infiltrating ductal carcinoma (IDC). Of 54 patients with either biopsy or at least 2 years’ follow-up, 9 (17 %) had cancer (95 % CI 8–29). Cancer was present in 7/42 (17 %, 95 % CI 7–31 %) lesions that had prompt histological confirmation (DCIS?=?5, IDC?=?2) and in 2/28 (7 %, 95 % CI 0.8–24 %) lesions referred for follow-up (DCIS?=?1, IDC?=?1). Neither calcification morphology (P?=?0.2), patient age (P?=?0.7), breast density (P?=?1.0), personal history (P?=?1.0) nor family history of breast cancer (P?=?0.5) had a significant association with cancer.

Conclusion

Calcifications not visualised on the stereotactic unit are not definitely benign and require surgical biopsy or follow-up. No patient or morphological features were predictive of cancer.

Key points

? Half of cancelled stereotactic biopsies were due to non-visualisation of calcified foci. ? This reflects the improved detection of calcifications by digital mammography. ? Calcifications too faint for the stereotactic technique require alternative biopsy or follow-up ? 17?% of patients with biopsy or at least 2 years’ follow-up had cancer. ? No patient/morphological features were found to aid selection for re-biopsy vs. follow-up.     

Calling all calcifications: a retrospective case control study

IntroductionThe majority of recalls from screening mammography do not result in biopsy recommendation. The purpose of this study was to evaluate if calcifications recalled from screening mammography are more likely to result in biopsy recommendations than other findings.MethodsIRB-approved electronic medical record search was performed to obtain a random sample of screening mammograms assigned BI-RADS 0 assessment during 2014–2015. Primary reason for recall was classified as mass, asymmetry, focal asymmetry, calcifications, or distortion. Primary outcome was biopsy performed after diagnostic work-up. Secondary outcome was proportion of biopsies performed that were positive for cancer, positive predictive value 3 (PPV3). Logistic regression was used to compare reasons for recall (calcifications vs other findings) with biopsy recommendation proportions.ResultsRandom database sampling yielded 402 screening examinations with BI-RADS 0 assessments with 449 total findings. Reasons for recall included calcifications (14.0%, 63/449), masses (15.8%, 71/449), asymmetries (50.8%, 228/449), focal asymmetries (14.3%, 64/449) and architectural distortions (5.1%, 23/449). Overall, 21.6% of recalls led to image-guided biopsy (87/402). Recalls for calcifications were more likely to result in biopsy compared with other types of findings (Adjusted OR 8.56, 95% CI 4.58 to 16.0, p < 0.001). No statistically significant differences were found in PPV3 proportions between calcification and non-calcification findings (p = 0.812).ConclusionRecalls for calcifications are much more likely to undergo biopsy compared with other findings. Increased biopsy rates for calcifications should be considered when recalling a patient from mammography screening in the context of practice specific positive predictive values and cancer detection rates.     

When is a diagnosis of sclerosing adenosis acceptable at core biopsy?

PURPOSE: To determine concordance of imaging findings and diagnosis of sclerosing adenosis at histopathologic core biopsy and to establish the accuracy of core biopsy when cancer was coexistent. MATERIALS AND METHODS: From a database of 1,166 percutaneous biopsies in which sclerosing adenosis was reported, 88 (7.5%) lesions were identified, and imaging and histopathologic findings were reviewed for concordance. Sclerosing adenosis proved to be a minor component at core biopsy for 44 lesions, including one invasive ductal carcinoma, one ductal carcinoma in situ (DCIS), one focus of atypical ductal hyperplasia (ADH), and one atypical lobular hyperplasia. Sclerosing adenosis was a major (> or =50%) component for 44 lesions, including four malignancies, all DCIS manifested as clustered calcifications (pleomorphic [n = 2] or amorphous [n = 2]), and seven foci of ADH manifested as amorphous calcifications. In 30 patients with 33 lesions without atypia or malignancy, sclerosing adenosis was the major finding at core biopsy (21 lesions at 14-gauge core biopsy and 12 at 11-gauge vacuum-assisted biopsy); these patients formed the study population. Mammographic (33 lesions) and sonographic (18 lesions) features were recorded. Twenty-seven lesions had at least 20-month follow-up (n = 25) or excision (n = 2). RESULTS: One spiculated mass was considered discordant and was excised, showing a prospectively unrecognized radial sclerosing lesion with several 2-5-mm foci of invasive tubular and lobular carcinoma. Seventeen (53%) of 32 lesions manifested as masses; 10 (59%) were circumscribed, five (29%) were indistinctly marginated (one with punctate calcifications), and two (12%) were partially circumscribed and partially obscured (one with amorphous calcifications). Fifteen (47%) lesions manifested as clustered calcifications; nine (60%) were amorphous and indistinct, four (27%) were pleomorphic, and two (13%) were punctate. Of 27 lesions with acceptable follow-up, 26 (96%) were believed to have been accurately sampled at core biopsy. Of six radial sclerosing lesions associated with the original 88 lesions, only three (50%) were prospectively recognized. CONCLUSION: Sclerosing adenosis is an acceptable result at core biopsy of circumscribed masses and nonpalpable indistinctly marginated masses and for clustered amorphous, pleomorphic, and punctate calcifications. Recognition and reporting of coexistent radial sclerosing lesions is encouraged and may prompt excision. Malignancy can be seen with sclerosing adenosis; core biopsy was accurate in six (86%) of seven coexistent malignancies in this series.