The impact of stereotactic large-core needle biopsy in the treatment of patients with nonpalpable breast lesions: a study of diagnostic accuracy in 510 consecutive cases

The objective of this study was to assess the usefulness of stereotactic large-core needle biopsy (LCNB) in the management of nonpalpable breast lesions (NBL) and compare it with stereotactic fine-needle aspiration biopsy (SFNA) performed simultaneously in a significant number of cases. From November 1993 through June 1997, 510 consecutive patients with NBL underwent 14-gauge LCNB with 354 women undergoing simultaneous 21-gauge SFNA in the same lesion. Mammographic findings, lesion size, number of core biopsy specimens, complications and diagnoses of both techniques were analysed. Surgical biopsy, tumorectomy or mastectomy was indicated for malignancy or poor correlation between SFNA or LCNB results and clinical or radiological findings. Values of diagnostic accuracy of both LCNB and SFNA were determined. The ratio benign surgical biopsies/malignant surgical biopsies (BB/CB) of the series was calculated. A total of 171 patients underwent surgical treatment; in 31 (18.1 %) a benign process or atypical ductal hyperplasia was the final diagnosis. The ratio BB/CB was 0.22. Sensitivity and specificity were 93.2 and 100 %, respectively, for LCNB, and 77.2 and 92.3 %, respectively, for SFNA with cytological analysis. Large-core needle biopsy provides more accurate diagnosis than SFNA in the management of nonpalpable breast lesions and obviates a surgical diagnostic procedure in a significant number of cases. Received 17 November 1997; Revision received 4 February 1998; Accepted 16 March 1998     

Comparison of a 1-day and a 2-day protocol for lymphatic mapping and sentinel lymph node biopsy in patients with nonpalpable breast cancer

Purpose  To compare the identification rate of the sentinel node in a 1-day protocol versus a 2-day protocol in patients with a nonpalpable breast carcinoma. Methods  In the 1-day protocol an average dose of 120 MBq ^99mTc-nanocolloid was injected intratumorally on the day of surgery, and in the 2-day protocol an average dose of 370 MBq ^99mTc-nanocolloid was injected intratumorally the day before surgery. Both a gamma ray detection probe and patent blue were used to locate the sentinel node. Results  In 57 of 67 patients (85%) treated in the 1-day protocol and in 51 of 56 patients (91%) treated in the 2-day protocol the sentinel node was detected (p=0.311). Of the patients in the 1-day protocol and the 2-day protocol, respectively, 18 (27%) and 13 (23%) showed metastasis (p=0.975) Conclusion  There was no significant difference in the identification rate of the sentinel node between the 1-day protocol and the 2-day protocol in patients diagnosed with a nonpalpable breast carcinoma.     

Comparison of stereotactic fine needle aspiration cytology and core needle biopsy in 522 non-palpable breast lesions

Purpose: 
To compare the accuracy of stereotactic fine needle aspiration cytologies (S-FNAC) and stereotactic core needle biopsies (S-CNB) in non-palpable breast lesions. Material and Methods: 
Between May 1993 and December 2000, 696 patients with mammographically detected lesions were biopsied both with S-FNAC and S-CNB. S-FNAC was performed with spinal needle 22- or 20-gauge and S-CNB with an automated 14-gauge gun. Results: 
Of the 696 patients, 522 (75%) underwent breast surgery with postoperative histopathology. In all, 448 of these 522 women (86%) had malignant and 74 (14%) had benign lesions. S-FNAC revealed cancer in 254 (57%) and probable cancer in 48 (11%) (sensitivity 68%, specificity 99.6%) and S-CNB revealed cancer in 388 (87%) and probable cancer in 18 (4%) (sensitivity 90%, specificity 98.8%) of these 448 patients. Conclusion: 
S-CNB was more accurate than S-FNAC in the diagnosis of non-palpable breast cancer.     

Performance of computer-aided diagnosis in the interpretation of lesions on breast sonography

RATIONALE AND OBJECTIVES: To investigate the potential usefulness of computer-aided diagnosis as a tool for radiologists in the characterization and classification of mass lesions on ultrasound. MATERIALS AND METHODS: Previously, a computerized method for the automatic classification of breast lesions on ultrasound was developed. The computerized method includes automatic segmentation of the lesion from the ultrasound image background and automatic extraction of four features related to lesion shape, margin, texture, and posterior acoustic behavior. In this study, the effectiveness of the computer output as an aid to radiologists in their ability to distinguish between malignant and benign lesions, and in their patient management decisions in terms of biopsy recommendation are evaluated. Six expert mammographers and six radiologists in private practice at an institution accredited by the American Ultrasound Institute of Medicine participated in the study. Each observer first interpreted 25 training cases with feedback of biopsy results, and then interpreted 110 additional ultrasound cases without feedback. Simulating an actual clinical setting, the 110 cases were unknown to both the observers and the computer. During interpretation, observers gave their confidence that the lesion was malignant and also their patient management recommendation (biopsy or follow-up). The computer output was then displayed, and observers again gave their confidence that the lesion was malignant and theirpatient management recommendation. Statistical analyses included receiver operator characteristic analysis and Student t-test. RESULTS: For the expert mammographers and for the community radiologists, the Az (area under the receiver operator characteristic curve) increased from 0.83 to 0.87 (P = .02) and from 0.80 to 0.84 (P = .04), respectively, when the computer aid was used in the interpretation of the ultrasound images. Also, the Az values for the community radiologists with aid and for the expert mammographers without aid are similar to the Az value for the computer alone (Az = 0.83). CONCLUSION: Computer analysis of ultrasound images of breast lesions has been shown to improve the diagnostic accuracy of radiologists in the task of distinguishing between malignant and benign breast lesions and in recommending cases for biopsy.     

Stereotactic, automated, large-core needle biopsy of nonpalpable breast lesions: false-negative and histologic underestimation rates after long-term follow-up

PURPOSE: To determine the rate and causes of false-negative findings and histologic underestimates at stereotactic biopsy of nonpalpable breast lesions. MATERIALS AND METHODS: Stereotactic, 14-gauge, automated, large-core needle biopsy (LCNB) was performed in 483 consecutive nonpalpable breast lesions. Excision was advised for the 143 carcinomas, 25 atypical ductal hyperplasia (ADH) lesions, and five radial scars. Mammographic follow-up was advised for the benign lesions without a repeat biopsy. RESULTS: Of the 310 benign lesions, 259 underwent mammographic follow-up at 6-85 months (median, 55 months) without repeat biopsy, 48 underwent repeat biopsy and three were lost to follow-up. On the basis of the histologic diagnosis of carcinoma at surgical biopsy, diagnosis with LCNB was not correct (i.e., disease was underestimated at histologic examination) in 14 (58%) of 24 ADH lesions and two (40%) of five radial scars. Two (1.2%) of 161 lesions with a final diagnosis of carcinoma were benign at LCNB but malignant at repeat biopsy (i.e., false-negative findings at LCNB). Repeat biopsy was prompted by mammographic progression at 6 and 18 months after LCNB. CONCLUSION: The false-negative rate with LCNB was 1.2% in this study and 4.0% in the literature. The presence of carcinoma in ADH and radial scar lesions was often underestimated.     

乳腺X线摄影引导下导丝定位在触诊阴性病灶切除术中的综合评价

目的 综合评价导丝导向定位术在触诊阴性乳腺病灶中的应用价值.方法 对84例触诊阴性乳腺病灶行导丝导向定位术103处,记录病灶大小、分布特征、标本体积、剂量参数和患者术中反应,评价病灶大小、特征、定位准确度对切除标本大小的影响以及定位术中辐射剂量和患者的耐受程度.结果 定位适中74处,过深14处,过浅9处,完全偏离病灶靶点6处.1次性切除病灶99处,4处病灶2次切除,标本平均体积为11.47cm^3.检出良性病变占59.2％（61/103处）;不典型增生8.7％（9/103处）;乳腺癌32.1％（33/103处）.定位术中辐射剂量近似为常规摄影辐射剂量的2倍,11例患者发生迷走反应.结论 立体定位导丝导向定位术可在完整切除病灶的同时缩小手术范围,是目前应用于触诊阴性的乳腺病灶的有效方法.病灶大小、分布特征和定位准确度是影响病灶切除体积大小的重要因素,且术中的高辐射剂量及患者在术中的护理均值得关注.     

Stereotactic biopsy of noncalcified breast lesions: utility of vacuum-assisted technique compared to multipass automated gun technique

The purpose of this study was to evaluate the stereotactic 14-gauge, vacuum-assisted biopsy technique in diagnosing noncalcified breast lesions. Stereotactic biopsy of 116 noncalcified breast lesions was performed with either 14-gauge, vacuum-assisted technique or multipass, automated large-core technique. The number of core samples and time required for each biopsy were compared. Outcome for each technique was compared based on recommendations after the mammographic-histologic review process. Results from surgical excision and mammographic follow-up were reviewed. The vacuum-assisted technique obtained more tissue cores per lesion than the automated gun technique, showed marginal decrease in number of repeat biopsies for discordant results, and required fewer short-term follow-up mammograms, although the difference did not achieve statistical significance. The vacuum-assisted technique can be used successfully to sample noncalcified breast masses, with marginal improvement over the automated gun technique.     

全数字化乳腺X线立体定位及活检技术对早期乳腺癌诊断及治疗的价值

目的探讨全数字化乳腺X线立体定位及活检技术对早期乳腺癌的诊断及治疗价值。资料与方法回顾性总结36例临床未触及病变,仅X线摄影发现乳腺微小病变患者的临床及影像资料,用全数字化X线立体定位导丝导向切除活检(stereotactic needle localized biopsy,SNLB)或核芯针穿刺活检(stereotactic core needle biopsy,SCNB)。结果 30例行SNLB患者中,29例一次性成功,成功率达96.7%;6例行SCNB者中,1例乳腺癌漏诊。结论应用全数字化乳腺X线立体定位及活检技术,可有效提高早期乳腺癌的诊断率,可对微创手术治疗提供精确的导向作用。     

Interventional MRI of the breast: lesion localisation and biopsy

With the growing use of breast MRI an increasing need exists for reliable MR-guided preoperative localisation or even MR-guided needle biopsy. In this article an overview is given of the different approaches and the present state of the art. With closed magnets the following approaches have been made: freehand localisation (similar to CT-guided freehand localisation), and freehand localisation combined with a frameless stereotaxic system operating with support by ultrasound. One localisation device for supine localisation and a thermoplastic mesh for breast stabilisation have been reported. Most investigators have used compression devices to immobilise the breast and prevent shift during needle insertion. Thus far, one immobilisation and aiming device has been designed for open magnets. A small number of experiences exist with interventions on open MR units using a navigation system. Wire localisations are presently a well-established procedure. Magnetic-resonance-guided needle biopsy has been accomplished in closed systems as well as by the use of breast immobilisation devices. However, problems still exist due to severe needle artefacts, tissue shift during the intervention and fast equalisation of contrast enhancement in lesions with surrounding tissue. Therefore, needle biopsy is not recommended for lesions < 10 mm. Magnetic-resonance-guided vacuum biopsy is somewhat more invasive but promises to solve most of these problems.     

Small vascular lesions of the breast diagnosed by magnetic resonance imaging‐guided vacuum assisted biopsy: Report of 2 cases

Vascular lesions of the breast comprise a heterogeneous group that includes a variety of benign, atypical, and malignant lesions. These are a diagnostic challenge given variable clinical, radiological and pathological presentation, especially when they are small and asymptomatic. We present 2 cases of these rare lesions of the breast which were occult to mammographics and ultrasound studies. Both the lesions were detected only on magnetic resonance imaging, most helpful in the diagnosis of these rare tumor. Histopathological examinations following the magnetic resonance guided biopsies, were initially interpreted as negative for breast cancer in both cases. These turned out to be respectively a low grade angiosarcoma and a benign vascular lesion after a new histopathological examination following a larger magnetic resonance guided biopsies performed in light of the radiology-pathology discordance. Although rare, it is important to consider vascular tumours of the breast; radiologists need to be aware such tumors may present non-specific imaging features.     

Touch-preparation cytologic examination of breast core biopsy specimens: Accuracy in predicting benign or malignant core histologic results

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the accuracy of touch-preparation cytologic examination of breast core biopsy specimens in predicting benign or malignant core histologic results. MATERIALS AND METHODS: One hundred two core biopsies were performed on 88 women with stereotactic or ultrasonographic (US) guidance. Slides were prepared by smearing one core sample on each slide, spraying the slides with fixative, and staining them with the Papanicolaou technique. Slides were blindly reviewed by a cytopathologist. Cytologic results were categorized as positive for malignancy, not diagnostic for malignancy, or insufficient for diagnosis. Results were correlated with histologic results from all specimens obtained during the core biopsy. RESULTS: Imaging depicted the lesions sampled for biopsy as masses (n = 70), clustered calcifications (n = 29), focal asymmetries (n = 2), or architectural distortion (n = 1). Touch-preparation slides of 87 (85%) lesions contained sufficient material for diagnosis. Cytologic results correctly identified 12 of 16 (three of five intraductal and nine of 11 invasive) malignancies in 10 of 13 masses and two of three clusters of calcifications. Two false-positive results occurred, both with fibroadenomas. Overall, touch-preparation studies produced 69 true-negative and four false-negative results. Excluding slides with insufficient material, the sensitivity, specificity, and accuracy of touch-preparation results were 75%, 97%, and 93%, respectively. Including insufficient samples, accuracy was 79%. CONCLUSION: Although touch-preparation cytologic examination of breast core biopsy specimens is fairly accurate in prediction of benign or malignant core histologic results, its correlation with histologic results is not sufficient to justify routine use in immediate counseling and treatment planning.     

Ultrasound-guided core needle biopsy of non-palpable breast lesions: a prospective analysis in 204 cases

Purpose: To assess the diagnostic value of ultrasound (US)-guided 14 G core needle breast biopsy in non-palpable suspicious breast lesions.

Material and Methods: From August 1997 to April 2001, 198 patients with 204 suspicious non-palpable breast lesions underwent US-guided large core needle biopsy. Biopsies were performed with a free-hand technique using US equipment with a 7.5 MHz linear-array transducer; a minimum of three cores were obtained from each lesion. Pathological findings in US-guided core biopsy were correlated to findings in subsequent surgery or long-term (more than 2 years) imaging follow-up.

Results: Among the 204 non-palpable breast lesions for which histopathological findings were obtained by US-guided core biopsy, 118 were malignant (114 carcinoma, 2 metastasis, 1 lymphoma, and 1 malignant phyllodes tumor) and 86 were benign (4 carcinoma and 82 benign lesions confirmed at surgery or after at least 2 years of follow-up). Sensitivity, specificity, positive predictive value, and negative predictive value for diagnosis of malignancy in our series were 97%, 100%, 100%, and 95%, respectively. Diagnostic yield with 1, 2, 3, and 4 specimens per lesion was 73.5%, 88%, 94%, and 97.5%, respectively.

Conclusion: US-guided core needle biopsy is a sensitive percutaneous biopsy method for diagnosing non-palpable breast lesions. To achieve a high diagnostic yield, a minimum number of three cores per lesion is advisable.     

Stereotactic large-core needle breast biopsy: analysis of pain and discomfort related to the biopsy procedure

The purpose of this study was to determine the significance of variables such as duration of the procedure, type of breast tissue, number of passes, depth of the biopsies, underlying pathology, the operator performing the procedure, and their effect on women’s perception of pain and discomfort during stereotactic large-core needle breast biopsy. One hundred and fifty consecutive patients with a non-palpable suspicious mammographic lesions were included. Between three and nine 14-gauge breast passes were taken using a prone stereotactic table. Following the biopsy procedure, patients were asked to complete a questionnaire. There was no discomfort in lying on the prone table. There is no relation between type of breast lesion and pain, underlying pathology and pain and performing operator and pain. The type of breast tissue is correlated with pain experienced from biopsy (P = 0.0001). We found out that patients with dense breast tissue complain of more pain from biopsy than patients with more involution of breast tissue. The depth of the biopsy correlates with pain from biopsy (P = 0.0028). Deep lesions are more painful than superficial ones. There is a correlation between the number of passes and pain in the neck (P = 0.0188) and shoulder (P = 0.0366). The duration of the procedure is correlated with pain experienced in the neck (P = 0.0116) but not with pain experienced from biopsy.     

Fine-needle aspiration biopsy of nonpalpable breast lesions in a multicenter clinical trial: results from the radiologic diagnostic oncology group V

PURPOSE: To determine the diagnostic accuracy of ultrasonographically (US) and stereotactically guided fine-needle aspiration biopsy (FNAB) in the diagnosis of nonpalpable breast lesions. MATERIALS AND METHODS: At 18 institutions, 442 women who underwent 22-25-gauge imaging-guided FNAB were enrolled. Definitive surgical, core-needle biopsy, and/or follow-up information was available for 423 (95.7%) of these women. The reference standard was established from additional clinical and imaging information for an additional six (1.4%) women who did not undergo further histopathologic evaluation. The FNAB protocol was standardized at all institutions, and all specimens were reread by one of two expert cytopathologists. RESULTS: When insufficient samples were included in the analysis and classified as positive, the sensitivity and specificity of FNAB were 85%-88% and 55.6%-90.5%, respectively; accuracy ranged from 62.2% to 89.2%. The diagnostic accuracy of FNAB was significantly better for detection of masses than for detection of calcifications (67.3% vs. 53.8%, P =.006) and with US guidance than with stereotactic guidance (77.2% vs. 58.9%; P =.002). CONCLUSION: FNAB of nonpalpable breast lesions has limited value given the high insufficient sample rate and greater diagnostic accuracy of other interventions, including core-needle biopsy and needle-localized open surgical biopsy.     

Diagnostic usefulness of water-to-fat ratio and choline concentration in malignant and benign breast lesions and normal breast parenchyma: an in vivo (1) H MRS study

Purpose:

To compare total choline concentrations ([Cho]) and water‐to‐fat (W/F) ratios of subtypes of malignant lesions, benign lesions, and normal breast parenchyma and determine their usefulness in breast cancer diagnosis. Reference standard was histology.

Materials and Methods:

In this HIPPA compliant study, proton MRS was performed on 93 patients with suspicious lesions (>1 cm) who underwent MRI‐guided interventional procedures, and on 27 prospectively accrued women enrolled for screening MRI. (W/F) and [Cho] values were calculated using MRS data.

Results:

Among 88 MRS‐evaluable histologically‐confirmed lesions, 40 invasive ductal carcinoma (IDC); 10 invasive lobular carcinoma (ILC); 4 ductal carcinoma in situ (DCIS); 3 invasive mammary carcinoma (IMC); 31 benign. No significant difference observed in (W/F) between benign lesions and normal breast tissue. The area under curve (AUC) of receiver operating characteristic (ROC) curves for discriminating the malignant group from the benign group were 0.97, 0.72, and 0.99 using [Cho], (W/F) and their combination as biomarkers, respectively. (W/F) performs significantly (P < 0.0001;AUC = 0.96) better than [Cho] (AUC = 0.52) in differentiating IDC and ILC lesions.

Conclusion:

Although [Cho] and (W/F) are good biomarkers for differentiating malignancy, [Cho] is a better marker. Combining both can further improve diagnostic accuracy. IDC and ILC lesions have similar [Cho] levels but are discriminated using (W/F) values. J. Magn. Reson. Imaging 2011;33:855–863. © 2011 Wiley‐Liss, Inc.     

MRI‐guided vacuum‐assisted breast biopsy: A phantom and patient evaluation of targeting accuracy

Purpose

To determine the spatial localization errors of magnetic resonance imaging (MRI)‐guided core biopsy for breast lesions using the handheld vacuum‐assisted core biopsy device in phantoms and patients.

Materials and Methods

Biopsies were done using a 10‐gauge handheld vacuum‐assisted core biopsy system (Vacora, Bard, AZ, USA) on a 1.5T MRI scanner (Philips Achieva, Best, The Netherlands). A standardized biopsy localization protocol was followed by trained operators for multiplanar planning of the biopsy on a separate workstation. Biopsy localization errors were determined as the distance from needle tip to center of the target in three dimensions.

Results

Twenty MRI‐guided biopsies of phantoms were performed by three different operators. The biopsy target mean size was 6.8 ± 0.6 mm. The overall mean three‐dimensional (3D) biopsy targeting error was 4.4 ± 2.9 mm. Thirty‐two MRI breast biopsies performed in 22 patients were reviewed. The lesion mean size was 10.5 ± 9.4 mm. The overall mean 3D localization error was 5.7 ± 3.0 mm. No significant differences between phantom and patients biopsy errors were found (P > 0.5).

Conclusion

MRI‐guided handheld vacuum‐assisted core biopsy device shows good targeting accuracy and should allow localization of lesions to within ～5 to 6 mm. J. Magn. Reson. Imaging 2009;30:424–429. © 2009 Wiley‐Liss, Inc.     

Fibrotic lesions of the breast: radiological findings and core-neddle biopsy results

Objectives

To evaluate the incidence of breast lesions with a histopathological diagnosis of focal fibrosis based on imaging guided core biopsy, to review the radiologic findings and to assess the diagnostic reliability of 14 G core needle biopsy.

Materials and methods

723 patients, who had undergone 14 G core biopsy and/or surgical excisions, were retrospectively analyzed. Overall, 43 lesions were diagnosed as focal fibrosis. Physical examination, mammography, ultrasonography, and follow-up findings were all reviewed.

Results

Radiological evaluation revealed that 35 (81%) lesions were solid masses. Of 35 mass lesions, 24 (69%) were well circumscribed, the remaining 11 (31%) lesions were ill defined on mammograms or sonograms. None of the lesions had pathological microcalcifications. Three lesions were surgically excised because of radio-pathological discordance after core needle biopsy.

Conclusions

Focal fibrosis of the breast is a benign condition and reflects the ductal and lobular atrophy secondary to stromal proliferation. The radiological findings of this entity may vary and sometimes mimic those of malignant lesions. The incidence of focal fibrosis among our study population is 6% and a well-defined mass lesion is the most frequent finding. Core needle biopsy is a safe and reliable diagnostic procedure in the management of these cases.