Large-needle core biopsy in atypical intraductal epithelial hyperplasia including immunohistochemical expression of high molecular weight cytokeratin: analysis of results of a single institution

The diagnosis of atypical intraductal epithelial hyperplasia (AIDH) constitutes 6.3% of the breast core biopsies performed at our institution. Seventy-nine cases that were diagnosed as AIDH on core biopsy and went through excisional biopsy were included. Sixty-four biopsies were performed by an image-guided 11-gauge vacuum device, 11 under sonographic guidance using 14-gauge needles and 4 by a sonographically guided 11-gauge vacuum device. The histopathology of the core biopsies and the surgical excisions were reviewed. Immunohistochemistry was performed on the consecutive sections of core biopsy specimens using high molecular weight cytokeratin (HMW-CK) (DAKO-Cytokeratin, 34βE12). At interpretation of the stain, intensity and percentage of positive cells were taken into account. The immunoprofiles of AIDH were categorized into four groups showing negative (i.e., no staining) or low-, moderate-, high-, and very high-intensity staining. Surgical excision of the 79 lesions revealed carcinoma in only 3 cases (4%)-two infiltrating carcinomas and one intraductal carcinoma—residual AIDH in 44 cases (56%), and epithelial hyperplasia or other benign lesions without atypia in 32 cases (40%). The HMW-CK stain was performed retrospectively on all of the core biopsies and 66 of them contained residual areas with AIDH for staining. Forty-nine (74%) were CK negative or stained with low intensity, but 17 cases (26%) had a moderate- to high-intensity stain. Our study showed a lower incidence of carcinoma on surgical excision following core biopsy for AIDH than other studies. The HMW-CK stain helped to characterize the nature of the intraductal proliferation and to confirm the presence of atypia, as has been previously reported, but frequently was inconclusive. The low incidence of carcinoma brings into question the need for surgical excision of all cases of AIDH diagnosed by core biopsy.     

Radial scars diagnosed on breast core biopsy: Frequency of atypia and carcinoma on excision and implications for management

AimsThe risk of finding carcinoma in excisions following a core needle biopsy diagnosis of radial scar is not well defined and clinical management is variable.The aim of this study is to determine the frequency of high-risk lesions, ductal carcinoma in situ, and invasive carcinoma in excisions following a core biopsy diagnosis of radial scar.Methods and resultsDedicated breast pathologists and radiologists correlated the histologic and radiologic findings and categorized radial scars as the target lesion or an incidental finding. High-risk lesions were defined as atypical hyperplasia or classical lobular carcinoma in situ.Of the 79 radial scars identified over a 14-year period, 22 were associated with atypia or carcinoma in the core biopsy. Thirty-seven (37) of the 57 benign radial scars underwent excision with benign findings in 30 (81%), high-risk lesions in six (16%), and flat epithelial atypia in one (3%). There were no upgrades to carcinoma. One patient with a benign radial scar developed a 3-mm focus of intermediate-grade estrogen receptor-positive ductal carcinoma in situ in the same quadrant of the ipsilateral breast 72 months after excision. One patient with an incidental un-excised benign radial scar was diagnosed with ductal carcinoma in situ at a separate site of suspicious calcifications.ConclusionsIn this series, none of the benign radial scars was upgraded to carcinoma. Radial scar was the targeted lesion in all cases with high-risk lesions on excision. Surgical excision may not be mandatory for patients with benign incidental radial scars on core biopsy.     

When pathological and radiological correlation is achieved,excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted

BackgroundThe diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up.MethodsA retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded.Results2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41–70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.     

Association of breast cancer with the finding of atypical ductal hyperplasia at core breast biopsy.

OBJECTIVE: The purpose of the study is to evaluate the prevalence of occult breast carcinoma in surgical breast biopsies performed on nonpalpable breast lesions diagnosed initially as atypical ductal hyperplasia (ADH) by core needle biopsy. BACKGROUND: Atypical ductal hyperplasia is a lesion with significant malignant potential. Some authors note that ADH and ductal carcinoma in situ (DCIS) frequently coexist in the same lesion. The criterion for the diagnosis of DCIS requires involvement of at least two ducts; otherwise, a lesion that is qualitatively consistent with DCIS but quantitatively insufficient is described as atypical ductal hyperplasia. Thus, the finding of ADH in a core needle breast biopsy specimen actually may represent a sample of a true in situ carcinoma. METHODS: Between May 3, 1994, and June 12, 1996, image-guided core biopsies of 510 mammographically identified lesions were performed using a 14-gauge automated device with an average of 7.5 cores obtained per lesion. Atypical ductal hyperplasia was found in 23 (4.5%) of 510 lesions, and surgical excision subsequently was performed in 21 of these cases. In these 21 cases, histopathologic results from core needle and surgical biopsies were reviewed and correlated. RESULTS: Histopathologic study of the 21 surgically excised lesions having ADH in their core needle specimens showed seven (33.3%) with DCIS. CONCLUSIONS: In the authors' patient population, one third of patients with ADH at core biopsy have an occult carcinoma. A core needle breast biopsy finding of ADH for nonpalpable lesions therefore warrants a recommendation for excisional biopsy.     

Intact Percutaneous Excision (IPEX) for Definitive Diagnosis of High-Risk Breast Lesions

Background  

Open surgical excision (OSE) is generally recommended when image-guided core needle breast biopsy demonstrates a high-risk lesion (HRL). We evaluated intact percutaneous excision (IPEX) with standard radiologic and histologic criteria for definitive diagnosis of HRL, particularly atypical ductal hyperplasia (ADH).The primary goal was to confirm criteria associated with <2% risk for upgrade to carcinoma, equivalent to risk associated with BI-RADS 3 lesions, for which imaging surveillance is considered sufficient.     

Vacuum-assisted stereotactic breast biopsy: histologic underestimation of malignant lesions

HYPOTHESIS: The histopathologic correlation between stereotactic core needle biopsy and subsequent surgical excision of mammographically detected nonpalpable breast abnormalities is improved with a larger-core (11-gauge) device. DESIGN: Retrospective medical record and histopathologic review. SETTING: University-based academic practice setting. PATIENTS: Two hundred one patients who underwent surgical excision of mammographic abnormalities that had undergone biopsy with an 11-gauge vacuum-assisted stereotactic core biopsy device. MAIN OUTCOME MEASURE: Correlation between stereotactic biopsy histologic results and the histologic results of subsequent surgical specimens. RESULTS: Results of stereotactic biopsy performed on 851 patients revealed atypical hyperplasia in 46 lesions, ductal carcinoma in situ (DCIS) in 89 lesions, and invasive cancer in 73 mammographic abnormalities. Subsequent surgical excision of the 46 atypical lesions revealed 2 cases of DCIS (4.3%) and 4 cases of invasive carcinoma (8.7%). Lesions diagnosed as DCIS on stereotactic biopsy proved to be invasive carcinoma in 10 (11.2%) of 89 patients on subsequent excision. Stereotactic biopsy completely removed 21 (23.6%) of 89 DCIS lesions and 20 (27.4%) of 73 invasive carcinomas. CONCLUSIONS: In summary, 11-gauge vacuum-assisted core breast biopsy accurately predicts the degree of disease in the majority of malignant lesions; however, understaging still occurs in 11% to 13% of lesions showing atypical hyperplasia or DCIS.     

A review of needle core biopsy diagnosed radial scars in the Welsh Breast Screening Programme

INTRODUCTION

Radial scars are benign breast lesions; their appearance on mammography may, however, mimic carcinoma. Needle core biopsy is performed for pre-operative diagnosis and, currently in Wales, all lesions with benign biopsy results are surgically excised. We have reviewed all cases of needle core biopsy-diagnosed radial scars from the Welsh breast screening programme, Breast Test Wales (BTW), and investigated the outcome of radial scars based on histology from surgical excision in order to evaluate the appropriateness of the current management of these lesions in Wales.

PATIENTS AND METHODS

All needle core biopsy diagnosed radial scars were identified from the BTW screening database from the start of screening in 1989 until the end of 2007.

RESULTS

A total of 118 patients were diagnosed with radial scars on needle core biopsy; two patients had bilateral radial scars. Median patient age was 54 years (range, 49-68 years). Ninety-five lesions (79%) were thought to be pure radial scars on needle core biopsy; however, only 81 pure radial scars were identified on excision biopsy histology. Carcinoma was present in seven patients and ductal carcinoma in situ in nine patients at excision biopsy. In two patients, the cancers occurred in lesions reported as pure radial scars on needle core biopsy. Twenty-two lesions showed atypical ductal or lobular hyperplasia (ADH/ALH) or both on excision biopsy; 14 of these lesions were classed as pure radial scars by needle core biopsy.

CONCLUSIONS

All core biopsy diagnosed radial scars, presenting as screen detected abnormalities, should be excised due to their association with premalignant and malignant conditions.     

Atypical ductal hyperplasia of the breast diagnosed by 11-gauge directional vacuum-assisted biopsy

BACKGROUND: Small nonpalpable mammographic abnormalities are frequently diagnosed by percutaneous stereotactically guided core needle biopsy. The reliability of the histologic diagnosis of atypical ductal hyperplasia (ADH) made from tissue obtained by 11-gauge directional, vacuum-assisted biopsy of these nonpalpable breast lesions is unknown. METHODS: The records of 31 patients who were found to have ADH by 11-gauge directional vacuum-assisted biopsy were reviewed. All of these patients subsequently underwent surgical excision with needle localization biopsy of the ADH and they are the subjects of this retrospective study. RESULTS: Eleven of the 31 patients with ADH on 11-gauge directional vacuum-assisted biopsy were upgraded to ductal carcinoma in situ or infiltrating carcinoma by the excisional biopsy. This was a 35% underestimation of malignancy in our patients. CONCLUSIONS: When the histologic diagnosis of ADH is made from tissue harvested by an 11-gauge directional vacuum assisted biopsy, surgical excision of the entire abnormality is recommended to avoid underdiagnosis of breast cancer.     

Clinicopathologic features of papillary lesions on core needle biopsy of the breast predictive of malignancy

BACKGROUND: The necessity for surgical excision of papillary lesions identified on percutaneous breast biopsy remains controversial. We reviewed data from patients with papillary lesions found on core needle biopsies to identify features associated with carcinoma. METHODS: A retrospective chart review was performed on patients with papillary lesions diagnosed from image-guided breast biopsies over a 10-year period. Patients had surgical excision or were followed-up radiographically for a 2-year minimum. RESULTS: Papillary lesions were identified in 154 core needle biopsies. Ninety-five lesions were diagnosed as either benign or atypical. Eighty-nine of these patients had surgical excisions of their lesions. Malignancy was discovered in 22 (25%) of these lesions. Only atypical lesions on biopsy were malignant (P < .005). Forty-six percent of patients age 65 or older were found to have cancer at surgical excision (P < .01). CONCLUSIONS: Papillary lesions found on core needle biopsy frequently harbor malignancy (25%). Atypia and age 65 or older are significant risk factors for malignancy.     

The Significance of Lobular Carcinoma In Situ and Atypical Lobular Hyperplasia of the Breast

Background

The significance of lobular neoplasia (LN), lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH)) found at core needle biopsy (CNB) of the breast remains uncertain. There is a consistent risk of underestimating malignancy after the diagnosis of LN on CNB. The aim of this study was to determine if patients with a CNB result of LN need surgical excision.

Methods

Patients were identified by searching the institutions pathology database for the terms ??lobular carcinoma in situ?? and ??atypical lobular hyperplasia?? over 20?years. Excluded from this study were those with core needle biopsy (CNB) results of ductal carcinoma in situ, atypical ductal hyperplasia, radial scar, or papilloma. Upgrade was defined as final surgical pathology of invasive carcinoma and/or ductal carcinoma in situ that was directly correlated to the site of the initial biopsy containing LN.

Results

LN was found at CNB in 285 patients, and 71?% (n?=?201) had subsequent surgical excisions. All patients with pleomorphic LCIS (pLCIS) underwent surgical excision. Following patients with pLCIS, patients with the diagnosis of LCIS were most likely to undergo surgical excision (80?%). Final pathology of the surgically excised specimens confirmed LN in 72?% (n?=?144). Also, 13?% (n?=?26) of the operated patients were upgraded to malignancy, including 8?% of ALH and 19?% of LCIS cases.

Conclusion

This is the largest series of surgical excisional pathology following LN on CNB ever reported. The likelihood of finding malignancy at surgical excision after CNB showing LN was 13?%. Patients with the diagnosis of LN on CNB should be considered for surgical excision.     

Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting

The diagnosis of atypical ductal hyperplasia (ADH) at needle core breast biopsy (NCB) is typically regarded as an indication for surgical excision. Although ADH is an intermediate risk nonobligate precursor lesion, the rationale for further therapy is the result of a reported high prevalence of a concomitant more advanced lesion (typically ductal carcinoma in situ) as the index lesion. To assess whether certain histopathologic features of ADH in NCB are predictive of open biopsy outcomes, the authors correlated the extent and pattern of ADH in 47 core biopsies (11-or 14-gauge) with the subsequent surgical specimen. Extent of ADH on NCB was ascertained by determining the number of large ducts and/or terminal duct-lobular units affected, with involvement of one large duct or one terminal duct-lobular unit representing a single focus, involvement of one duct and one terminal duct-lobular unit as two foci, and so on. Of the 47 cases, ADH was restricted to < or =2 foci in 24 cases (51.1%), confined to 3 foci in 8 cases (17.0%), and involved > or =4 foci in 15 cases (31.9%). The corresponding histopathologic findings at excision were benign lesions without atypia (n = 14), focal residual ADH (n = 13), atypical lobular hyperplasia (n = 3), ductal carcinoma in situ (n = 15), and invasive mammary carcinoma (n = 2). When the number of foci of involvement by ADH on NCB (based on an average of 11.6 cores per case) was correlated with the open biopsy results, all cases of ADH limited to < or =2 foci had no worse lesion on excision, whereas ADH present in > or =4 foci was found to be a strong predictor of a more advanced lesion on excision (p <0.0001, chi2). When histologic pattern was evaluated, all cases of pure micropapillary ADH on NCB showed pure micropapillary ductal carcinoma in situ on excision.     

Imaging-Guided Core Biopsy of the Breast

Abstract: This article reports on our experience with core needle biopsy (CNB) of the breast and presents a review of the literature. We have performed CNB on 304 women with abnormalities classified on imaging as highly suggestive of malignancy (52 cases), suspicious (245 cases) or probably benign (7 cases). The CNB procedure was performed using either stereotactic mammographic guidance (251 cases) or ultrasound guidance (53 cases) with a 14-gauge needle. At least five specimens were obtained for each abnormality. The sensitivity of core biopsy was 98% and the specificity was 99%. There were three false negatives and one false positive. An excisional biopsy was recommended in 17 cases in which the CNB diagnosis was not definitive, including 12 with atypical ductal hyperplasia (ADH), 4 with discordance between imaging and histologic results, and 1 with inconclusive histology. Our results are consistent with other reports in the literature using 14-gauge core needle biopsy. In our practice, core biopsy has proven to be an effective method for the evaluation of imaging findings that are suspicious or highly suggestive of malignancy.     

The Contribution of Cytologic Imprints of Stereotactically Guided Core Needle Biopsies of the Breast in the Management of Patients with Mammographic Abnormalities

Abstract: Between 1995 and 1996, 96 consecutive patients with nonpalpable breast lesions detected by abnormal mammogram underwent core needle biopsies under stereotactic guidance at Johns Hopkins Bayview Medical Center. The cytologic diagnoses rendered on touch imprints and the histopathologic diagnoses made on the core needle biopsies were retrospectively reviewed to ascertain the accuracy and the validity of this procedure. These imprints were made of the cores as on-site evaluation in order to assist the radiologist. Separate diagnoses were rendered on the imprints and the cores. Follow-up excisional/open biopsies were then correlated to determine the usefulness of making touch imprints from the core needle biopsies toward the overall management of a patient with an abnormal mammogram. The core needle biopsies were obtained with a 14-gauge needle and biopsy gun. The cytologic diagnoses rendered on touch imprints and histopathologic diagnoses on core needle biopsies were compared and the concordance rate was determined. The subsequent surgical follow-up was analyzed and correlated with the imprint cytology and the core needle biopsy interpretation to ascertain the pathologic outcome. A total of 100 cases were reviewed: 4 patients had two lesions biopsied. Eighty-four cases showed complete cytohistologic correlation, that is, a high concordance rate. These 84 cases were divided into four categories: malignant (24), atypical 2 , benign (55), and unsatisfactory 3 . Of these concordant cases, there were 34 subsequent excisional biopsies and all except one confirmed the core needle biopsy diagnosis. The exception had a benign touch imprint and core but the excisional biopsy showed multifocal ductal carcinoma in situ. Of the 100 cases, 16 were nonconcordant (the cytologic diagnosis fell into a different category from the histologic diagnosis). Seven of these nonconcordant cases resulted in excisional biopsies and all but one showed the core diagnosis to be correct. The only exception was a case with atypical cytology and a benign core biopsy with the follow-up excision showing atypia. The rest of the nonconcordant cases with atypical imprints and benign cores had no follow-up surgery, showing that the clinicians are inclined to depend on the core biopsy diagnosis. While our study demonstrates the accuracy and concordance of cytologic touch imprints, the surgical follow-up data reveal that there does not appear to be any additive value to rendering a separate diagnosis on touch imprints of core needle biopsies.     

Surgical and mammographic follow-up of papillary lesions and atypical lobular hyperplasia diagnosed with stereotactic vacuum-assisted biopsy

The purpose of this study was to assess the accuracy of stereotactic vacuum-assisted biopsy (SVAB) for the diagnosis of high-risk lesions, which include papillary lesions and atypical lobular hyperplasia (ALH). Retrospective review was performed of 212 consecutive SVABs at our institution between May 1, 2000 and February 28, 2001. Biopsies were performed using an 8-gauge SVAB probe, with the patient prone on a dedicated stereotactic table. Eleven to 17 cores (mean 12.4) were harvested from each lesion. Radiography of core specimens was performed in cases in which the targeted lesion contained microcalcifications. Six of the lesions (2.8%) demonstrated intraductal papilloma, 1 (16.7%) of which had features suggestive of a radial scar, and 7 (3.3%) demonstrated ALH. Surgical excision was performed on 3 of the 6 (50%) papillomas and all 7 (100%) cases of ALH. Histopathologic analysis at surgical excision demonstrated benign breast tissue in 1 of the papillomas (33.3%), radial scar in 1 (33.3%), and atypical ductal hyperplasia (ADH) in 1 (33.3%). One papilloma not surgically excised underwent repeat mammography at 6 months and demonstrated no change. Of the surgically excised lesions with ALH, 4 (57.1%) retained the diagnosis of ALH, though one of these (25%) also demonstrated a coexisting radial scar. One lesion (14.3%) demonstrated ductal carcinoma in situ (DCIS), 1 (14.3%) demonstrated lobular carcinoma in situ (LCIS), and 1 (14.3%) demonstrated fibrocystic change. Lesions diagnosed as papillomas at SVAB did not demonstrate malignancy, but 2 (66.7%) were found to contain high-risk lesions that may impact surveillance or prophylactic therapy (i.e., tamoxifen). Because of the relatively small series reported, additional studies are necessary to further assess the accuracy of SVAB in the diagnosis of benign papillary lesions. ALH diagnosed with SVAB that underwent subsequent surgical excision demonstrated cancer in 1 of 7 lesions (14.3%). This rate of cancer underestimation is similar to that seen with ADH diagnosed with SVAB, which warrants surgical excision to rule out malignancy. Therefore we recommend that lesions demonstrating ALH at SVAB be considered for surgical excision to rule out malignancy.     

Ductal carcinoma in situ and atypical ductal hyperplasia of the breast diagnosed at stereotactic core biopsy

Abstract: Stereotactic core needle biopsy (SCNB) allows specific histopathologic diagnoses to be made without surgery and has been demonstrated to be an accurate, cost-effective method of diagnosing breast disease, particularly nonpalpable lesions. However, recent studies have concluded that the diagnosis of atypical ductal hyperplasia (ADH) by means of SCNB has resulted in nearly equal odds that a coexisting malignant lesion will be missed. Furthermore, others have concluded that SCNB diagnosed as DCIS cannot reliably indicate the absence of tumor invasion in surgical excision. Between 1993 and 1998, 1,221 consecutive SCNB of mammographically identified lesions were performed using a 14-gauge automated device with an average of 5.3 cores obtained per lesion. ADH was identified in 19 (1.6%) lesions and DCIS in 89 (7.3%). Surgical biopsy was performed in 89 of these patients and histopathologic results from SCNB and surgical biopsies were reviewed and correlated. In 12 cases of ADH diagnosed by SCNB, surgical biopsy showed ADH in 8 (67%) cases and DCIS in the other 4 (33%) cases. In 77 cases of DCIS diagnosed by SCNB, a surgical biopsy showed DCIS in 55 (71%) cases, 6 more cases (8%) had DCIS with focal microinvasion, and 15 (19%) had invasive ductal carcinoma. In one case no residual tumor was found at surgery. In the author's patient population, the diagnosis of ADH at SCNB indicates high probability of DCIS or residual ADH in the surgical biopsy. The diagnosis of DCIS at SCNB is confirmed in the majority of surgical biopsies; however, a significant number of cases may show microinvasion or invasive carcinoma.     

The clinical significance of lobular neoplasia on breast core biopsy

A core biopsy diagnosis of atypical ductal epithelial hyperplasia is upstaged on follow-up excisional biopsy (FUEB) to in situ or invasive carcinoma in about 20% of cases, thus prompting a FUEB. In contrast, upstaging information for a core biopsy diagnosis of pure lobular neoplasia (LN), without mass lesions or other risk-associated lesions is less clear. In this retrospective study, we report the largest consecutive series of patients who had a breast core biopsy diagnosis of LN and a FUEB. Core needle breast biopsies with a diagnosis of LN were retrieved from our files for the period 1999 to 2005, yielding 110 patients. One hundred and one patients had a follow-up surgical excision. Cases of LN with coexisting high-risk lesions (n=9, 10%) were excluded from the study. Patients with associated mass lesions all had benign findings (n=15, 16%) and had no impact on the study results. The remaining 77 core biopsies had no masses or risk lesions and were mammographically Breast Imaging Reporting and Data System 4 (BIRADS) for microcalcifications. Overall, 8/77 (10%) of patients with a radiographic BIRADS 4 image with calcifications and a core biopsy diagnosis of LN on core biopsy were upstaged on FUEB to ductal carcinoma in situ or invasive carcinoma. The numbers upstaged from core biopsies were as follows: atypical lobular hyperplasia (ALH) 4/52 (8%), mixed ALH/lobular carcinoma in situ (LCIS) 1/9 (10%), and pure LCIS 3/16 (19%). A core biopsy of LCIS with neoplastic epithelial calcifications was nearly 3 times more likely to be upstaged on FUEB compared with ALH. We conclude that a finding of LN on breast core biopsy in a patient with a BIRADS 4 image and calcifications is associated with a risk of 8% to 19% of upstaging to a treatable disease on FUEB.     

The management of lobular neoplasia identified on percutaneous core breast biopsy

The management of lobular neoplasia (LN) found on percutaneous core biopsy remains a clinical dilemma. The purpose of this study was to establish guidelines for the management of LN when obtained on percutaneous core needle biopsy. A retrospective review of the Breast Imaging Tissue Sampling Database at New York Presbyterian Hospital-Columbia Comprehensive Breast Center was performed from 1998 to 2000. A total of 1460 percutaneous core breast biopsies were performed using 11- or 14-gauge needles with LN identified in 43 biopsies from 34 patients. Eleven biopsies were ultrasound guided for nonpalpable masses and 32 were stereotactically guided for mammographically detected densities (10) and microcalcifications (22). The 43 LN biopsies were divided into three groups based on additional findings associated with LN on core biopsy: group I (n = 19), LN with invasive cancer or ductal carcinoma in situ (DCIS); group II (n = 11), LN plus a second indication for open surgical biopsy, such as atypical ductal hyperplasia (ADH), radial scar, phyllodes tumor, or intraductal papilloma; and group III (n = 13), LN plus benign fibrocystic changes. In group I, 19 of 19 biopsies (100%) yielded invasive cancer or DCIS on surgical biopsy versus 3 of 11 (27%) for group II, and 1 of 13 (8%) for group III. Outcomes in group III are described as follows: three patients were lost to follow-up, three patients did not undergo surgical biopsy but demonstrated more than 1 year of mammographic stability following core biopsy. Of the remaining seven patients, two had LN and ADH on surgical biopsy (one had a contralateral cancer), one had atypical lobular hyperplasia (with a contralateral cancer), two had LN and benign fibrocystic changes, one had LN and intraductal papilloma, and one had LN and invasive ductal carcinoma (IDC) with DCIS (with a contralateral cancer). These results suggest that surgical biopsy is indicated for patients with LN when found on core biopsy and when the biopsy demonstrates invasive cancer, DCIS, or other indications for surgical biopsy such as ADH, or in the examination of a patient with a synchronous contralateral breast cancer. The diagnosis of LN alone without these indications on percutaneous biopsy may not warrant routine surgical biopsy.     

Biopsy needle technique and the accuracy of diagnosis of atypical ductal hyperplasia for mammographic abnormalities

The evaluation of mammographic abnormalities has become a substantial effort for surgeons and radiologists. The vacuum-assisted core biopsy (VACB) has been touted as a more accurate tool for the evaluation of mammographic lesions. Diagnosis of atypical ductal hyperplasia (ADH) from a percutaneous needle biopsy of the breast is associated with a significant risk of missing a significant breast lesion. We compared 2 methods of sampling with stereotactic-guided breast biopsy, 14-gauge automated gun core biopsy (AGCB) and VACB, on the accuracy of diagnosis of ADH at a single institution. All cases of ADH, without associated malignancy, found via image-guided breast biopsy of nonpalpable lesions between March 1996 and April 2002 were evaluated. VACB biopsy needles were utilized between July 1998 to April 2002 (686 patients) and 14-gauge AGCB from March 1996 to June 1998 (350 patients). The results of these biopsies were reviewed and compared to surgical biopsy and pathological records. ADH alone was found in 53 cases (5.1% of biopsies; mean age 57.9 years). Of these, 39 patients with ADH subsequently underwent wire-localized excisional biopsy. The other 14 patients were observed. VACB biopsy understaged 7 of 29 (24%) patients with ADH (all of which were DCIS), AGCB understaged 4 of 10 cases (40%) with one being invasive. Of the patients in the core biopsy group who were initially followed, 2 developed significant lesions within 3 years of follow-up in the same quadrant of the breast. If these cases are added to the AGCB group, then 50 per cent were understaged and significantly more invasive lesions were understaged than with VACB (17% vs. 0%; P = 0.018). The VACB resulted in less understaging of ADH than AGCB. However, there remains a significant risk of missing DCIS in this setting even with the VACB. Furthermore, the risk of understaging an invasive lesion is significantly lower in this setting with a VACB than an AGCB. Although the risk of understaging ADH is lower with the VACB, we continue to recommend excisional biopsy in a good-risk patient when a diagnosis of ADH is rendered via VACB biopsy.     

Role of microbiopsy in diagnostic and therapeutic approach of mammary suspect microcalcification

PURPOSE: To determine the sensibility, the specificity, the positive and negative predictive values of microcalcifications detection by core needle biopsy and intra-operative pathologic examination. MATERIALS AND METHODS: A hundred and one patients (between 1998 and 1999) were investigated in this retrospective study. The initial presentation was breast microcalcifications without palpable tumour. The mean age of patients was 55 (34-79) years. Mammography was performed in 3 standard projections. All suspect microcalcifications were recommended for surgical excision. In the others cases, 5 core biopsies were taken of the lesion. Needle guidance was accomplished by means of either dedicated stereotaxic device or ultrasound equipment. All biopsies were performed with a biopsy device fitted with 14 G needles. The mean follow-up period was 3 years. RESULTS: Clinical or surgical follow-up was available in 101 lesions. Only 4 benign lesions did not have surgery. The 97 remaining were subsequently excised. Pathologic study showed cancer in 38 (39%) lesions, carcinoma in-situ in 14 lesions, and benign disease in 45 lesions. There was 1 false-negative biopsy. The specificity and sensitivity of percutaneous biopsy diagnosis were 73,6 and 93,7% respectively. Intra-operative pathologic diagnoses were concordant in 77% of 30 cases. Discordance occurred in 2 cases of atypical hyperplasia with a single false-negative result for a carcinoma that led to an additional surgical procedure. Positive and negative predictive values of intra-operative pathologic diagnosis were 82 and 100% respectively. CONCLUSION: Needle biopsy findings are accurate and allow definitive therapeutic surgery, including mastectomy.