Osseous metaplasia of the breast: diagnosis with stereotactic core biopsy

There are approximately 200 reported cases of breast tumors containing areas of bone. The majority of the neoplasms are sarcomas, phylloides tumors, or fibroadenomata. We present a case of osseous metaplasia mammographically detected by clustered heterogeneous calcifications. Stereotactic core biopsy revealed the presence of well-formed bone tissue without associated neolplasia. The case represents the first reported case of mammographically detected osseous metaplasia confirmed by core biopsy.     

Stereotactic core needle biopsy of mammographic breast lesions as a viable alternative to surgical biopsy

Background: Stereotactic needle biopsy technique has received considerable attention as a possible alternative to surgical biopsy of nonpalpable breast lesions. The exact role of this procedure in the management of mammographic breast lesions has not yet been accurately defined. Methods: Data have been collected prospectively on 416 patients over an 8-month period (January 1992 through August 1992). Of 416, 356 patients underwent only stereotactic breast biopsy with a 14-gauge needle. Sixty patients underwent stereotactic breast biopsy followed by surgical biopsy. Based on mammographic findings before biopsy, lesions were classified as benign (24%), likely benign (49%), malignant (2%), likely malignant (6%), and indeterminate (19%). The number of core biopsy specimens obtained from each patient ranged from one to six. Results: The specimen was considered adequate in 98% of cases. Complications were minimal. The tissue diagnosis was benign in 92% and malignant in 8% of patients. In those patients undergoing surgical and stereotactic biopsy, 57 of 60 had matching histopathological results, representing an agreement rate of 95% (p<0.001). The three patients whose histopathological results did not match had malignant diagnoses on stereotactic biopsy that were subsequently not identified in the modified radical mastectomy specimen because the entire focus of malignancy was removed by the several passes made by the core needle during biopsy. No patient had a negative stereotactic biopsy result in whom malignancy was later detected by surgical biopsy. Conclusions: This study indicates excellent agreement between surgical and stereotactic needle biopsy findings. Stereotactic biopsy with a 14-gauge needle could obviate the need for surgical biopsy in certain women with radiologically benign, likely benign, and indeterminate lesions. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Follow‐up outcomes of benign vascular lesions of breast diagnosed on core needle biopsy: A study of 117 cases

Benign vascular lesions of breast are uncommon findings on core biopsy and surgical excision has been recommended to rule out a more serious lesion. However, a recent study suggested that excision may be spared for vascular lesion without atypia. The aim of this study was to assess the follow‐up outcomes in lesions yielding benign vascular lesions on core biopsy. We retrospectively reviewed 117 patients with diagnosis of hemangioma (106 patients) and atypical hemangioma (11 patients) on core biopsy at our institution over an 18‐year period. Majority of benign vascular lesions were followed‐up clinically and/or radiologically. Surgical excision was performed on 18 patients (16.9%) with benign hemangiomas and all 11 patients (100%) with atypical hemangiomas. Upon excision, the majority of patients (82.8%, 24/29) retained benign final pathology and five patients (17.2%) were atypical hemangioma. There was no upgrade on excision. All patients had a benign course regardless whether the lesions were excised or not. Our findings support the recent study that benign vascular lesion of breast may not require surgical excision.     

Imaging and management of fibroepithelial breast lesions on percutaneous core needle biopsy

The purpose of this study is to review the clinical presentation, multi‐modality appearance, and management of the most common benign and malignant fibroepithelial lesions of the breast. Fibroepithelial lesions of the breast may exhibit characteristic features on mammography, ultrasound, and MRI, although definitive diagnosis most often requires biopsy and at times, surgical excision. Knowledge of the imaging features can assist in refining the differential diagnosis and guiding appropriate management.     

A case report of pseudoaneurysm after a core needle biopsy of breast cancer

Breast pseudoaneurysms after a core needle biopsy are a rare complication with a low incidence. However, it is important to be aware of the possibility of complications that require treatment.     

Diagnostic accuracy of vacuum-assisted biopsy device for image-detected breast lesions

Background : Non‐palpable breast lesions present diagnostic difficulties. Ultrasound‐guided fine‐needle aspiration cytology (FNAC) is a common method used to obtain a diagnosis, but FNAC is frequently inconclusive or insufficiently accurate. Recently a vacuum‐assisted biopsy device (Mammotome^®, Ethicon, Endo‐surgery, USA) has been introduced. The diagnostic accuracy of this biopsy device was assessed for lesions that were visible on ultrasound. Methods : Fifty ultrasound‐guided mammotome biopsies were performed. All were small breast lesions primarily detected by ultrasound. All received FNAC as initial assessment. Mammotome biopsy was performed whenever the breast lesion was considered indeterminate or if it was considered benign and there were associated risk factors such as a family history of breast cancer. Results : Of 50 mammotome biopsies 45 had benign histology. Three of 45 lesions were excised at the patients’ request and were confirmed to be benign. The remaining 42 patients received an ultrasound follow up at 6 months. The lesion size remained static in 39 patients. In three patients the lesion size increased and they were excised and histology was benign. For the four malignancies diagnosed with mammotome biopsy, three patients received definitive treatment and one patient defaulted. There was one failed mammotome biopsy in the present series. Conclusions : Mammotome biopsy is an acceptable diagnostic method for small breast lesions seen on ultrasound. It reduces the need for open biopsy without compromising diagnostic accuracy.     

Preoperative core biopsy of soft tissue tumours facilitates their surgical management: a 10-year update

Background: Soft tissue sarcomas (STS) are rare. More often than not, the possibility of STS is not considered preoperatively and the lesions are enucleated. Enucleation (excisional biopsy) is inappropriate for sarcomas as it compromises the planning of definitive surgery and radiotherapy. Incisional biopsy has been regarded as the biopsy of choice by some, but it has a high rate of wound complications. The aims of the study were (i) to assess the current accuracy of core biopsy in the diagnosis of STS; (ii) to assess whether preoperative core biopsy facilitates the surgical management of soft tissue tumours; and (iii) to evaluate whether there has been an increase in the use of core biopsy before referral. Methods: Patients with soft tissue tumours managed by a surgeon with a special interest in soft STS from 1994 to 2007 were reviewed from data collected in a database prospectively. The accuracy of core biopsy in the diagnosis of soft tissue tumours and planning of definitive surgery were assessed. Results: Ninety‐four patients with 98 lesions were reviewed. Sixty‐eight lesions had core biopsy. The overall sensitivity of core biopsy in diagnosing soft tissue tumours was 83.6%. It has a sensitivity of 91.3% and specificity of 100% for malignant STS. For patients who had core biopsy, 95% had one‐stage surgery; those who had no core biopsy, only 45% had one‐stage surgery (P value <0.001). Conclusions: Core biopsy is accurate in the diagnosis of soft tissue tumours. It is safe and does not have the complications of open biopsy. It enables most patients to have one‐stage surgery.     

术中标本摄片用于乳腺可疑钙化病变组织活检

目的 观察术中标本摄片用于乳腺可疑钙化病变组织活检的价值。方法 对48例乳腺单发可疑钙化病变患者行X线三维立体定位引导活检术,对其中12例行核芯针穿刺活检(SCNB)、22例行真空辅助旋切活检(SVAB)、14例行导丝定位手术切检(SNLB),术中以标本摄影系统对组织标本行X线摄片,之后对标本中的钙化进行标记并送病理检查;评估标本摄片在3种活检方式中显示钙化的清晰度及组织学低估情况,观察SNLB术中标本摄片所示钙化数目及切缘状态,并与术前乳腺X线片进行比较。结果 所有标本均获得目标钙化组织。术中标本摄片显示钙化清晰度优于术前乳腺X线片,显示SNLB组织内钙化数量多于术前乳腺X线片。14例SNLB中,12个术中标本摄片显示切缘阴性,与术后病理结果一致;2个切缘阳性,且钙化呈多灶性分布,术中快速冰冻切片结果均为恶性并切缘阳性,手术计划由保乳手术改为乳腺癌改良根治术。SCNB、SVAB活检结果及SNLB术中冰冻切片结果与手术病理结果均一致。结论 术中标本摄片用于乳腺可疑钙化病变组织活检具有一定价值。     

A novel way of hook wire placement for surgical resection of suspicious breast lesions using the stereotactic vacuum assisted breast biopsy table

Preoperative hook localization is a necessary procedure for targeting impalpable breast lesions. The aim of the current study is to introduce an alternative technique of wire placement by using the stereotactic biopsy device instead of the conventionally used mammography device. Fifty-one patients with impalpable mammographic lesions, graded BIRADS 4 or 5, were prospectively enrolled. Mean duration was 7 ± 1.5 minutes. Lesion-to-wire distance was <1 cm in 96% (51/53). Hook wire placement using the stereotactic biopsy device is considered as a safe, accurate, fast, and well-tolerable for the patient procedure.     

Diagnosis of breast lesions by aspiration biopsy cytology

From November 1981 to the end of August 1984, 456 patients with breast lesions underwent aspiration biopsy cytology (A.B.C.). This study includes 109 for whom the diagnosis was histologically confirmed at surgical biopsy. Seventy-five lesions were histologically proven to be malignant and 34 were benign. The accuracy of diagnoses with A.B.C. was; true positive 86.7 per cent (65/75) of the time, true negative 82.6 per cent (28/34) of the time, false negative 5.3 per cent (4/75) of the time and false positive 5.7 per cent (2/34) of the time. Unsatisfactory or inadequate aspirated tissue made A.B.C. diagnosis difficult in 5.5 per cent (6/109) of the cases. Three out of 7 with malignant tumors, who were wrongly diagnosed as benign by A.B.C., had tumors with a diameter of 1.0 cm or less. Two benign cases which were falsely diagnosed as malignant also had small tumors about 1.0 cm in diameter. Although A.B.C. is more reliable than other conventional supplementary diagnostic techniques (mammography, ultrasonography, etc.), it is important to carefully follow clinically questionable cases which appear negative, using A.B.C.     

Mucocele‐like lesions diagnosed on breast core biopsy: Low risk of upgrade and subsequent carcinoma

Mucocele‐like lesions of the breast diagnosed on core biopsy are usually excised to exclude the possibility of partial sampling of an invasive mucinous carcinoma. The goal of this study was to correlate the pathologic and radiologic features of mucocele‐like lesions to determine if excision is mandatory. Over a 16 year period we identified 32 patients with mucocele‐like lesions diagnosed on 27 (84%) stereotactic and 5 (16%) ultrasound‐guided core biopsies. The indications for core biopsy were: calcifications in 24 (75%), a mass in 7 (22%), and a mass with calcifications in 1 (3%). There were 22 (69%) mucocele‐like lesions without atypia and 10 (31%) with atypical ductal hyperplasia or detached groups of atypical cells. Of the 22 mucocele‐like lesions without atypia, 19 (86%) were excised: 15/19 (79%) were benign, 3/19 (16%) had atypical ductal hyperplasia and 1/19 (5%) had ductal carcinoma in situ. None of the patients with mucocele‐like lesions without atypia were upgraded to invasive carcinoma. The single patient who was upgraded to low‐grade ductal carcinoma in situ had a history of ductal carcinoma in situ in the same breast. Of the 10 patients with mucocele‐like lesions with atypia, 9 (90%) were excised: 5/9 (56%) were benign, 1/9 (11%) had atypical ductal hyperplasia and 3/9 (33%) had invasive carcinoma. Of the patients with mucocele‐like lesions with atypia who were upgraded to invasive carcinoma, one had a BIRADS 5 mass and discordant pathology and one had a history of Hodgkin lymphoma and mantle radiation. There were 24 patients with mucocele‐like lesions with or without atypia who were not upgraded on excision, and none developed breast cancer after a median of 51 months (range 7‐192). These findings indicate that mucocele‐like lesions without atypia are unlikely to be upgraded on excision and are associated with a low risk for the subsequent development of carcinoma.     

A prospective study of the use of fine-needle aspiration cytology and core biopsy in the diagnosis of breast cancer

A prospective study was carried out on 143 consecutive patients with palpable lumps larger than 2 cm in size which were clinically suspicious of carcinoma. One hundred and five lumps proved to be malignant and 38 were benign. Of the 105 patients with malignancy, confirmation was made in 95 by fine-needle aspiration cytology (FNAC) with a sensitivity of 90.4% and 100 by core biopsy with a sensitivity of 95.2%. The sensitivity of core biopsies increased with the number of cores taken (one core, 76.2%; two cores, 80.9%, three cores, 89.2%; four cores, 95.2%). The combined sensitivity of FNAC and core biopsies was 100%, and so are complementary in the accurate diagnosis of breast cancer. Patients presenting to the breast clinic with a solid suspicious breast lump larger than 2 cm can benefit from FNAC and a minimum of four core biopsies to improve diagnosis.     

How image‐guided core needle biopsies altered the treatment of breast disease: Challenges accepted and opportunities taken

The technique of combining stereotactic targeting of breast lesions with an automated spring‐loaded needle biopsy gun reported in 1990 by Steve Parker and colleagues not only ushered in the era of diagnosis almost exclusively by image guided core needle biopsy, but also profoundly changed the practice of pathologists, radiologists, surgeons, and medical oncologists and had major effects on the treatment of women with breast cancer. In this special issue of The Breast Journal celebrating 25 years of publication, it is of value to reflect back on these changes, some expected and some unanticipated, which have occurred over the past three decades and to consider the reasons why core needle biopsies should be considered a milestone in breast pathology.     

Feasibility and safety of image‐guided vacuum‐assisted breast biopsy: A PRISMA‐compliant systematic review and meta‐analysis of 20 000 population from 36 longitudinal studies

Breast cancer is a serious disease in women. We estimated the global technical success rate and complication rates of percutaneous vacuum‐assisted breast biopsy (VABB). PubMed, Embase, Web of Science, and Scopus databases were retrieved up to July 2018 to find studies in which technical success rate and complication rates of VABB were available. Pooled rates were calculated according to location mode (ultrasonography [US] or mammography) and needle type (8‐ or 11‐gauge Mammotome probes). Of the 36 articles with 20 868 cases, we found the pooled technical success rate 0.9999(0.9997, 1.0000) (I ² = 17.1%, P = .187) and low complication risks including haematoma 0.1092(0.0748, 0.1437) (I ² = 98.3%, P < .001), pain 0.0738(0.0334, 0.1141) (I ² = 95.9%, P < .001), vasovagal reflex 0.0281(0.0035, 0.0527) (I ² = 92.5%, P < .001), and infection 0.0027(−0.0019, 0.0073) (I ² = 49.8%, P = .113). In this systematic review and meta‐analysis, the pooled data suggested that VABB with US or mammography could be promising for diagnosis and treatment of breast disease. Further studies were necessary to identify strategies for these findings.     

超声联合空芯针穿刺活检在原发性乳腺癌腋窝淋巴结转移中的诊断价值

目的研究术前超声引导下淋巴结空芯针穿刺(US-CNB)在检测乳腺癌患者腋窝淋巴结转移中的诊断价值。方法回顾性研究2016年1月至2017年7月在我院行超声检查及超声引导下空芯针穿刺活检,并有腋窝淋巴结术后病理诊断的所有乳腺癌病人。计算US-CNB的敏感性、特异性、阳性预测值(PPV)、阴性预测值(NPV)、准确性,同时统计Kappa值以明确一致性情况。分析US-CNB结果与N和T分期的关系。结果以术后病理结果为金标准,US-CNB诊断淋巴结转移的敏感性为91.8%(90/98),特异性为58.3%(21/36),PPV为85.7%(90/105),NPV为72.4%(21/29),误诊率为41.7%(15/36),漏诊率为8.2%(8/98),约登指数为50.1%,准确性82.8%(111/134),ROC曲线下面积为0.751。比较US-CNB与术后病理的一致性,Kappa=0.535。排除新辅助化疗患者14例,特异性、PPV和误诊率分别为95.5%(21/22)、98.9%(90/91)以及4.5%,约登指数87.3%,准确性92.5%(111/120),ROC曲线下面积为0.936(P0.0001),比较排除后US-CNB与术后病理的一致性,Kappa=0.777。随着T和N分期的增加,US-CNB的敏感性增加。结论乳腺癌患者术前腋窝淋巴结空芯针穿刺可作为诊断腋窝淋巴结转移的可靠方法,与术后病理有较高的一致性。淋巴结穿刺结果阳性可能与乳腺癌较高肿瘤负荷相关。     

Papillary lesions of the breast diagnosed by core needle biopsy: 71 cases with surgical follow-up

Background

Papillary breast lesions comprise a spectrum of histopathologic diagnoses ranging from benign papillomas to papillary carcinomas. There is ongoing controversy regarding the management of papillary lesions diagnosed by core needle biopsy (CNB). Some authors advocate observation of papillary lesions when the CNB is benign, while others recommend surgical excision of all papillary lesions. The current study assessed the adequacy of CNB in evaluating papillary breast lesions.

Methods

A search of the pathology database at our institution identified 122 papillary lesions diagnosed by CNB. The study population consisted of 71 papillary lesions that were subsequently surgically excised.

Results

Of the 71 papillary lesions excised, 8 were malignant, 16 were atypical, and 47 were benign at the time of CNB. Of the 47 papillary lesions thought to be benign, 13 (28%) revealed atypia and 4 (9%) revealed malignancy upon surgical excision. Of the 13 atypical papillary lesions on CNB, 7 lesions (54%) were associated with malignancy upon excision. Slightly over half the upgrades were due to finding atypia or malignancy in the tissue surrounding the papillary lesion. The total rate of upgrades from the CNB diagnosis to the excisional diagnosis was 38%.

Conclusions

When a core biopsy of a papillary lesion is encountered, there is a strong likelihood of discovering atypia or malignancy in the index lesion or in close proximity. Therefore, surgical excision should be performed to avoid missing a malignancy and to allow for accurate breast cancer risk assessment that can impact survival and decisions regarding chemoprevention.     

Rates and indications for surgical breast biopsies in a community-based health system

Background

High rates of surgical breast biopsies in community hospitals have been reported but may misrepresent actual practice.

Methods

Patient-level data from 5,757 women who underwent breast biopsies in a large integrated health system were evaluated to determine biopsy types, rates, indications, and diagnoses.

Results

Between 2008 and 2010, 6,047 breast biopsies were performed on 5,757 women. Surgical biopsy was the initial diagnostic procedure in 16% (n = 942) of women overall and in 6% (72 of 1,236) of women with newly diagnosed invasive breast cancer. Invasive breast cancer was diagnosed in 72 women (8%) undergoing surgical biopsy compared with 1,164 (24%) undergoing core needle biopsy (P < .001, age adjusted). Main indications for surgical biopsies included symptomatic abnormalities, technical challenges, and patient choice.

Conclusions

Surgical biopsy was the initial diagnostic procedure in 16% of women with breast abnormalities, comparable with rates at academic centers. Rates could be improved by more careful consideration of indications.     

Screen‐detected breast cancer compared to symptomatic presentation: An analysis of surgical treatment and end‐points of effective mammographic screening

Background : Mammographic screening has been shown to reduce mortality from breast cancer and to offer more opportunity for breast conservation surgery (BCS). The minimum standards (or surrogate end‐points) that need to be achieved by a screening programme if it is to reduce mortality have been derived from the Two County Study. Three surrogate end‐points that can be used to gauge the quality of the screening service are that 50% of the identified infiltrating cancers should be < 15 mm; at least 30% of grade 3 cancers should be < 15 mm; and 70% of screen‐detected cancers should have a negative axillary dissection. The present study assesses these end‐points of effective screening in an urban population referred to The Strathfield Breast Centre (TSBC). The screening end‐points and surgical treatment of one group of women referred with a BreastScreen New South Wales (NSW)‐detected breast cancer (screen group) were compared to all the other, mostly symptomatic, breast cancer referrals (symptom group). The problems with the current pattern of acceptance of mammographic screening in TSBC’s referral area are discussed. Methods : A prospective non‐randomized study was done via analysis of the prospective database at The Strathfield Breast Centre (TSBC). Results : There were 224 women in the screen group and 657 women in the symptom group. The mean tumour size was 18.1 mm in the screen group and 22.1 mm in the symptom group. There were significantly more small invasive cancers (< 15 mm) in the screen group (58%) compared with the symptom group (33%; P < 0.001). In the screen group there were more low‐grade tumours but 30% of grade 3 tumours were < 15 mm compared with 16% in the symptom group (P = 0.009). In patients with invasive cancers who underwent axillary dissection, there was a significant difference in axillary node negativity, being 72% in the screen group and 59% in the symptom group (P = 0.003). In the screen group 64% of women had BCS compared with 51% in the symptom group (P = 0.002). Conclusions : These end‐points of effective mammographic screening were met in the BreastScreen NSW group of women who were referred to TSBC despite the biases involved which could lessen the effectiveness of the screening programme. This crudely translated into a significant reduction in breast cancer mortality but selection and lead time bias has to be taken into account in evaluation of these data. There was a significantly greater chance of BCS in the screen group.     

Impact of core biopsy on the management of screen-detected ductal carcinoma in situ of the breast

Background: Screen‐detected ductal carcinoma in situ (DCIS) usually presents as clinically impalpable microcalcification. Although core biopsy is well established as a diagnostic modality for invasive breast cancers, few reports address its impact on the management of screen‐detected DCIS. We examined the sensitivity of core biopsy in diagnosing screen‐detected DCIS, as well as its role in facilitating one‐step surgery in the community, especially a breast‐conserving approach. Methods: Through the Monash BreastScreen database, we reviewed the management of 148 patients diagnosed with pure DCIS over a 4‐year period. Particular attention was paid to the sensitivity and surgical margin status of 63 patients who underwent initial assessment with core biopsy, compared to patients who underwent excisional biopsy or fine needle aspiration cytology (FNAC). Results: Core specimens in 63 patients yielded positive histology in 57 (90%), allowing for breast‐conserving surgery in 45 and mastectomy in 12. Negative margins were obtained in 73% of those treated by breast‐conserving surgery, compared to 51% negative margins among those who underwent excisional biopsy initially. Overall, 45 of 57 patients with a positive core biopsy histology (79%) underwent one‐step surgery. Those assessed by FNAC had a 48% incidence of non‐diagnostic/benign cytology. Conclusions: Core biopsy facilitates one‐step surgery for screen‐detected DCIS, and potentially reduces the number of surgical procedures. Stereotactic core biopsy for suspicious microcalcifications should replace hookwire‐guided excisional biopsy and FNAC as the diagnostic modality of choice.     

SiteSelect: minimally invasive excision of breast lesions

The goal of screening mammograms is to provide early detection of breast cancer. As mammography technology improves, the ability to detect smaller and smaller suspicious lesions is increased. However, as mammography cannot always differentiate between malignant and benign lesions, biopsies are often needed. With the decreasing size of lesions seen on mammography, the size of the biopsy specimen needed for diagnosis also decreases. Thus, a smaller amount of normal breast tissue needs to be removed during a biopsy. For a majority of the small lesions, excision with a small margin of normal breast tissue is sufficient for diagnosis. The SiteSelect procedure utilizes stereotactic guidance to excise completely a tumor that is noted on a mammogram. The procedure can be performed under local anesthesia through a minimal incision (usually 1.5 cm). The SiteSelect™ biopsy procedure completely excises small tumors noted on the mammogram with minimal trauma to the breast tissue and with excellent cosmetic results. It is well tolerated by patients. For tumors requiring only local excision, such as atypical ductal hyperplasia or lobular carcinoma in situ, the SiteSelect procedure may be the only diagnostic procedure required.