Directional Vacuum-assisted Biopsy Research Articles

Flat epithelial atypia in directional vacuum-assisted biopsy of breast microcalcifications: surgical excision may not be necessary

AbstractThe aim of this study was to analyze the clinicopathological features of patients with flat epithelial atypia, diagnosed in directional vacuum-assisted biopsy targeting microcalcifications, to identify upgrade rate to in situ ductal or invasive breast carcinoma, and determine factors predicting carcinoma in the subsequent excision. We retrospectively evaluated the histological, clinical, and mammographic features of 69 cases from 65 women, with directional vacuum-assisted biopsy-diagnosed flat epithelial atypia with or without atypical ductal hyperplasia or atypical lobular hyperplasia, which underwent subsequent surgical excision. The extent and percentage of microcalcifications sampled by directional vacuum-assisted biopsy were evaluated by mammography. All biopsy and surgical excision slides were reviewed. The age of the women ranged from 40 to 85 years (mean 57 years). All patients presented with mammographically detected microcalcifications only, except in one case that had associated architectural distortion. Extent of calcifications ranged from <1 cm (n = 47), 1–3 cm (n = 15) to > 3 cm (n = 6), and no measurement (n = 1). A mean of 11 cores (range 6–25) was obtained from each lesion. Post-biopsy mammogram revealed >90% removal of calcifications in 81% of cases. Pure flat epithelial atypia represented nearly two-thirds of directional vacuum-assisted biopsy specimens (n = 43, 62%), while flat epithelial atypia coexisted with atypical ductal hyperplasia (18 cases, 26%), or atypical lobular hyperplasia (8 cases, 12%). Upon excision, none of the cases were upgraded to in situ ductal or invasive breast cancer. In one case, however, an incidental, tubular carcinoma (4 mm) was found away from biopsy site. Excluding this case, the upgrade rate was 0%. Our study adds to the growing evidence that diagnosis of flat epithelial atypia on directional vacuum-assisted biopsy for microcalcifications as the only imaging finding is not associated with a significant upgrade to carcinoma on excision, and therefore, excision may not be necessary. Additionally, excision may not be necessary for flat epithelial atypia with atypical ductal hyperplasia limited to ≤2 terminal duct-lobular units, if at least 90% of calcifications have been removed on biopsy.

Abstract P4-14-10: Atypical Ductal Hyperplasia diagnosed on directional vacuum-assisted biopsy: is surgical excision mandatory?

Abstract Background: The incidence of atypical ductal hyperplasia (ADH) is increasing due to mass screening. Because of the underestimation risk of malignancy, the management remains controversial. Our goal was to analyze clinicopathologic features of patients with ADH diagnosed on directional vacuum-assisted biopsy (DVAB). The objectives of this continuous retrospective study were to evaluate the underestimation rate of malignancy and to identify predictors of upgrade to carcinoma. Methods: Between 2003 and 2010, 3159 patients underwent stereotactic DVAB in our institute. We retrospectively evaluate clinical, mammographic and pathological features of 298 cases of ADH who underwent surgical excision in our center (93.1%). Patients with concurrent history of breast cancer, intraductal carcinoma (DCIS) associated, or with no follow-up or surgical excision on place were excluded. Histological scar of macrobiopsy was systematically searched in surgical specimens. A pathologic upgrade was defined by presence of invasive cancer or DCIS on surgical specimen. Statistical tests used were the chi-square or Fisher's exact test. Results: Among the 298 studied DVAB, 224 ADH were isolated (75.2%), 46 associated to flat epithelial atypia (15.4%) and 28 to lobular neoplasia (9.4%). 98.4% patients presented microcalcifications at diagnosis. In 52 cases, lesions were upgraded to DCIS (n = 38) or invasive cancer (n = 14). The underestimated rate was 17.5%. In 67.3% cases, upgrade lesions were low or intermediate grade DCIS. Only the history of contralateral breast cancer was significantly correlated with the underestimated rate (p = 0.04). There was no statistical difference between these 52 cases and the 246 others for: family history, size of calcification, sampling number, histological lesion, and quality of calcifications removal. Conclusions: In this study, DVAB may not be considered a therapeutic procedure in case of ADH, even in the case of complete removal of microcalcifications. It is still challenging to identify a subgroup of ADH cases with a low upgrade rate. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-10.

Identifying Patients with Atypical Ductal Hyperplasia Diagnosed at Core-Needle Biopsy Who Are at Low Risk of Malignancy

HomeRadiologyVol. 257, No. 3 PreviousNext CommunicationsLetters to the EditorIdentifying Patients with Atypical Ductal Hyperplasia Diagnosed at Core-Needle Biopsy Who Are at Low Risk of MalignancyConstance T. Albarracin*, Christopher V. Nguyen*, Gary J. Whitman†, Wei Weiang†, Nour Sneige* Constance T. Albarracin*, Christopher V. Nguyen*, Gary J. Whitman†, Wei Weiang†, Nour Sneige* Author AffiliationsDepartments of Pathology* and Diagnostic Radiology† University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030e-mail: [email protected]Constance T. Albarracin*Christopher V. Nguyen*Gary J. Whitman†Wei Weiang†Nour Sneige* Published Online:Dec 1 2010https://doi.org/10.1148/radiol.101253MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Kohr JR, Eby PR, Allison KHet al.. Risk of upgrade of atypical ductal hyperplasia after stereotactic breast biopsy: effects of number of foci and complete removal of calcifications. Radiology 2010;255(3):723–730. Link, Google Scholar2 Ely KA, Carter BA, Jensen RA, Simpson JF, Page DL. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol 2001;25(8):1017–1021. Crossref, Medline, Google Scholar3 Forgeard C, Benchaib M, Guerin Net al.. Is surgical biopsy mandatory in case of atypical ductal hyperplasia on 11-gauge core needle biopsy? a retrospective study of 300 patients. Am J Surg 2008;196(3):339–345. Crossref, Medline, Google Scholar4 Nguyen C, Albarracin CT, Whitman G, Lopez A, Sneige N. Atypical ductal hyperplasia in directional vacuum-assisted biopsy of breast microcalcifications: considerations for surgical excision. Ann Surg Oncol [in press]. Google Scholar5 Sneige N, Lim SC, Whitman GJet al.. Atypical ductal hyperplasia diagnosis by directional vacuum-assisted stereotactic biopsy of breast microcalcifications: considerations for surgical excision. Am J Clin Pathol 2003;119(2):248–253. Crossref, Medline, Google Scholar6 Wagoner MJ, Laronga C, Acs G. Extent and histologic pattern of atypical ductal hyperplasia present on core needle biopsy specimens of the breast can predict ductal carcinoma in situ in subsequent excision. Am J Clin Pathol 2009;131(1):112–121. Crossref, Medline, Google ScholarArticle HistoryPublished online: Dec 2010Published in print: Dec 2010 FiguresReferencesRelatedDetailsCited ByComplex General Surgical Oncology: A Case-Based Approach - Volume 1VanceSohn2013Multidisciplinary Considerations in the Management of High-Risk Breast LesionsSavitriKrishnamurthy, ThereseBevers, HenryKuerer, Wei T.Yang2012 | American Journal of Roentgenology, Vol. 198, No. 2Definitive Diagnosis for High-Risk Breast Lesions Without Open Surgical Excision: The Intact Percutaneous Excision Trial (IPET)Pat W.Whitworth, Jean F.Simpson, William R.Poller, Steven M.Schonholz, John F.Turner, Rogsbert F.Phillips, Joel M.Johnson, F. DavidMcEachin2011 | Annals of Surgical Oncology, Vol. 18, No. 11Radiopaedia.orgRohitSharma, TheRadswiki2010Accompanying This ArticleErrataMar 1 2011RadiologyRecommended Articles Underestimation Rate at MR Imaging–guided Vacuum-assisted Breast Biopsy: A Multi-Institutional Retrospective Study of 1509 Breast BiopsiesRadiology2016Volume: 281Issue: 3pp. 708-719Ductal Carcinoma in Situ: State-of-the-Art ReviewRadiology2021Volume: 302Issue: 2pp. 246-255Growth Dynamics of Mammographic Calcifications: Differentiating Ductal Carcinoma in Situ from Benign Breast DiseaseRadiology2019Volume: 292Issue: 1pp. 77-83Digital Mammography Stereotactic Biopsy versus Digital Breast Tomosynthesis–guided Biopsy: Differences in Biopsy Targets, Pathologic Results, and Discordance RatesRadiology2020Volume: 294Issue: 3pp. 518-527High-Risk Breast Lesions: A Machine Learning Model to Predict Pathologic Upgrade and Reduce Unnecessary Surgical ExcisionRadiology2017Volume: 286Issue: 3pp. 810-818See More RSNA Education Exhibits How to Recognize Ductal Carcinoma in SITU: Tips for New ResidentsDigital Posters2020Catch Me Before I Go Invasive! The Role of Ultrasound in Depicting Calcified and Non-Calcified DCISDigital Posters2019Help Your Pathologist Help You: Successfully Arriving at a Diagnosis on Breast BiopsyDigital Posters2019 RSNA Case Collection Breast Papillomatosis with DCISRSNA Case Collection2020Ductal carcinoma in situRSNA Case Collection2020Invasive Papillary CarcinomaRSNA Case Collection2020 Vol. 257, No. 3 Metrics Altmetric Score PDF download

Atypical Ductal Hyperplasia in Directional Vacuum-Assisted Biopsy of Breast Microcalcifications: Considerations for Surgical Excision

Our goal was to analyze clinicopathologic features of patients with atypical ductal hyperplasia (ADH) diagnosed on directional vacuum-assisted biopsy (DVAB) targeting microcalcifications to identify factors predicting the presence of carcinoma. We retrospectively evaluated the clinical, mammographic, and histologic features of 140 patients with DVAB-diagnosed ADH who underwent either segmental excision (86.4%) or mammographic follow-up (≥2years; 13.6%). Cases with mass lesions or ipsilateral cancer were excluded. In 16 cases, carcinoma was found on excision. All cases without excision showed no new abnormalities on mammographic follow-up. Only the amount of calcifications removed (≤95%) significantly correlated with the rate of upgrade of ADH to carcinoma (P=.037). Significant histologic predictors of upgrade to carcinoma included number of terminal duct-lobular units (TDLU; >2) involved (P=.0306), presence of significant cytologic atypia suspicious for intermediate or high-grade carcinoma (P<.0001), and necrosis (P=.0006). Among ADH cases without significant atypia and/or necrosis, the extent of ADH (≤2 vs. >2 TDLU involved) was not a significant predictor of carcinoma (P=1.0000). ADH associated with calcifications in the absence of a mass lesion can be categorized into different risk groups using a multidisciplinary approach with correlation of histologic and mammographic findings. ADH lesions with significant cytologic atypia and/or necrosis are most likely to be associated with carcinoma and should be excised. ADH without these features, regardless of extent of involvement, and with >95% removal of the targeted calcifications, is associated with a minimal risk (<3%) of carcinoma and may undergo mammographic follow-up only.

Use of a hemostasis introducer sheath to guide clip delivery during stereotactic directional vacuum-assisted breast biopsy when the biopsy system malfunctions

Stereotactic directional vacuum-assisted breast biopsy (ST DVAB) is an accurate biopsy method. Marking the biopsy site with a clip is mandatory after ST DVAB, in case excision is required. With the ST DVAB system we use, clip was delivered through the biopsy probe. We report a case with malfunctioning of the ST DVAB system during the procedure, and thus the clip could not be placed through the biopsy probe. To salvage the procedure, we placed the clip to the biopsy site via a hemostasis introducer sheath.

Sonographic changes after removing all benign breast masses with sonographically guided vacuum-assisted biopsy

Total removal of benign breast masses by vacuum-assisted biopsy (VAB) is now increasingly accepted as a treatment option. However, little is known about whether this procedure produces early changes on follow-up sonography and, if so, how often and what factors might influence them. To evaluate sonographic changes after total removal of benign breast masses using sonographically guided VAB and to determine the influencing factors. We evaluated sonographic changes prospectively 1 week, 1 month, and 6 months after biopsying 32 benign masses from which all sonographic evidence had been removed during sonographically guided directional VAB performed with 8- or 11-gauge needles. Procedural factors were documented and compared with sonographic findings. At 1-week follow-up, hematomas were observed in 84% (27/32) of the lesions. After 1 month, while the hematomas had resolved in all but five lesions, focal new architectural distortion had developed in 26 (90%) lesions; 11 lesions were graded as severe, mimicking malignancy. After 6 months, 23 lesions with various degrees of architectural distortion were observed. Six of the 32 lesions (19%) contained a residual lesion. No statistically significant association between sonographic findings and procedural variables was identified, except between the degree of hematoma and lesion size. The total removal of benign breast masses using sonographically guided VAB frequently produces changes on follow-up sonography after 6 months. Although these changes failed to show statistical significance with procedural factors, a larger dedicated study is needed.

Stereotactic directional vacuum-assisted breast biopsy using lateral approach

In recent years, stereotactic vacuum-assisted breast biopsy [so-called Mammotome® biopsy (ST-MMT)] has been established as a reliable method for diagnosis of nonpalpable and mammographically detected lesions with microcalcification. However, there are few reports regarding the lateral approach. We performed ST-MMT using the lateral approach. The purpose of this study was to determine the usefulness of the lateral approach. 124 women with microcalcifications underwent stereotactic vacuum-assisted breast biopsy (median age, 52.5 years). All underwent stereotactic biopsy using the lateral approach. We compared our data with those of other institutes using the vertical approach. We removed microcalcifications and used an 11-gauge vacuum-assisted probe in all cases. The range of breast thickness was 10-45 mm. 12 patients had vasovagal reactions, however they quickly recovered without drug intervention. No patients had major complications. Of 124 cases, cancer was diagnosed in 37 patients. In other institutes using the vertical approach, it was impossible to use 11G probes in some cases due to the breast being too thin. In our study, minimum breast thickness was 10 mm (7 cases) and we were able to use 11G probes in all 7 cases with only polyethylene foam. With the lateral approach, it is possible to use 11G probes if the breast is thin (in our study minimum thickness was 10 mm) with only polyethylene foam. We believe this to be an advantage of the lateral approach. This advantage is very important in stereotactic biopsy, especially in Japan, as Japanese women's breasts are generally thinner than most Western women's.

Use of Bayesian Modeling to Estimate the Sensitivity of Stereotactic Directional Vacuum-Assisted Breast Biopsy When the Gold Standard is Incomplete

This study is conducted to estimate the sensitivity of stereotactic directional vacuum-assisted breast biopsy (ST DVAB) using Bayesian modeling and to predict how many more cancers can be inferred from those lesions without surgical correlation. We retrospectively reviewed the 103 lesions from 84 women who underwent ST DVAB. The study was approved by the Institutional Review Board of our hospital. We estimated the sensitivity and prevalence of the study population for ST DVAB by two types of approaches: for the type I approach, the gold standards were surgical correlation or postbiopsy mammographic follow-up. For the type II approach using Bayesian modeling by a beta-binomial model, the only gold standard was surgical correlation and the predicted number of cancerous lesions in those patients without surgical correlation was estimated. For the type I approach, the sensitivity was 92.3%, and the prevalence 12.6%. For the type II approach, the mean sensitivity of ST DVAB was 89%, and the mean prevalence was 15%. We predicted that an average of 1.7 cancerous lesions occurred among those lesions without surgical correlation by the Bayesian estimation. The mean sensitivity of ST DVAB using the Bayesian (type II) approach was lower than that using the type I approach, because we regarded the surgery as the only gold standard in Bayesian modeling and the nonoperated lesions were thought to be with unknown true disease status. The Bayesian approach is thus more appropriate to use than the type I approach when the gold standard is incomplete.

The use of positive core wash cytology to estimate potential risk of needle tract seeding of breast cancer: directional vacuum-assisted biopsy versus automated core needle biopsy

A disadvantage of the image-guided core needle biopsy is that needle tract seeding may occur and affect the local recurrence and overall survival rates of patients after breast-conserving surgery, although the chance is small. The purpose of this study was to compare the potential risk of needle tract seeding of breast cancer from ultrasonographically guided needle biopsies that were performed with a directional vacuum-assisted device and an automated core needle gun. The study compared the biopsies of 148 breast cancers performed using ultrasonographically guided core needle biopsy with the biopsies of 105 breast cancers performed using the vacuum suction probe. The potential risk of needle tract seeding of the breast cancer was defined by the cytological results derived from the needle wash material. The atypical/indeterminate, suspicious/probably malignant, and malignant categories were considered to represent positive cases. There were significantly fewer positive cytological findings derived from the needle wash material with the directional vacuum-assisted device (33%) than with the automated core needle gun (69%) (P < 0.0001). The use of the directional vacuum-assisted device significantly decreases the potential risk of needle tract seeding of breast cancer after an ultrasonographically guided needle biopsy.

Abnormal mammography and sonography associated with foreign-body giant-cell reaction after stereotactic vacuum-assisted breast biopsy with carbon marking

Carbon marking of the biopsy site and needle track following stereotactic breast biopsy in nonpalpable mammography-detected lesions provides for safe and accurate localization for subsequent surgical excision. No significant complications of carbon marking have been reported to date. To report follow-up imaging findings and histological changes (foreign-body giant-cell reaction) attributable to the use of carbon marking after vacuum breast biopsies. This was a retrospective study of 130 patients in a mammographic screening program with nonpalpable suspicious breast lesions that were referred for stereotactic directional vacuum-assisted breast biopsy with carbon marking. Histological diagnosis was benign in all cases, but 1-year follow-up mammograms demonstrated suspect findings in four of them. For all four patients, the results of the initial stereotactic vacuum-assisted biopsy were benign, but mammographic follow-up and ultrasound findings revealed suspicious changes that, in all cases, were histologically shown to be foreign-body giant-cell reactions attributable to the use of carbon. In four of 130 lesions (3%) that were carbon marked following stereotactic vacuum-assisted breast biopsy, and in which surgical excision was not required, the mammographic and ultrasound follow-up appearance of the breast simulated malignancy. The abnormality was attributable to the use of carbon, which represents a potential source of misdiagnosis.

Pain and complications of directional vacuum-assisted stereotactic biopsy: Comparison of the Mammotome and Vacora techniques

Objective The aim of our study is to compare the Mammotome and Vacora methods of stereotactic directional vacuum-assisted biopsy in terms of pain and complications. Materials and methods From June 2001 to May 2005, 1114 consecutive patients underwent directional stereotactic vacuum-assisted breast biopsy (DVAB) for nonpalpable mammographically detected breast lesions (BI-RADS 3, 4 or 5). Respectively 967 and 147 patients underwent the Mammotome and Vacora procedures. Pain was evaluated with a visual analog scale. Immediate and late complications were recorded. Results The mean ± S.D. (range) pain scores in the Mammotome and Vacora groups were 1.7 ± 1.8 (0–9) and 2.9 ± 2.3 (0–10), respectively ( p < 0.001). Patient age and operator experience were the main determinants of pain. Immediate complications were significantly more frequent in the Mammotome group ( p = 0.003), and so were late hematomas ( p = 0.04). Moderate and severe complications occurred exclusively in the Mammotome group. Conclusion The Mammotome technique is associated with a higher risk of immediate and late complications, while the Vacora technique is associated with more frequent severe pain. Patient age was the major factor influencing pain. Further prospective studies are needed to clarify factors incriminated in pain or complications after DVAB procedures.

Accuracy of ultrasound-guided, large-core needle breast biopsy

Ultrasound-guided, large-core needle biopsy (US-LCNB) of suspicious breast lesions is acknowledged as less invasive and less expensive and less time consuming than surgical biopsy, and provides a histologic diagnosis with a comparable high degree. US-LCNB has been proven to help reduce the number of unnecessary surgeries for benign disease. Its limitations, however, are false-negative results and underestimation of disease. Thus, the demand for breast teams is to carefully adhere to the principles of triple assessment and imaging-histologic correlation, and follow-up of lesions with a specific benign histology after biopsy. Also, the acceptance of guidelines and rigorous quality controls help to reliably minimize the delay in the diagnosis of breast cancer in patients with false-negative biopsies. This paper aims to summarize the equipment and methods as well as the benefits and limitations of US-LCNB. Also, guidelines of quality assessment are suggested. Finally, recent developments which may help to overcome the limitations of US-LCNB will be discussed, i.e., directional vacuum-assisted biopsy (VAB), three-dimensional (3D) US-guided biopsy, as well as the use of tissue harmonic imaging (THI) and compound imaging (CI) during biopsy.

Preoperative computed tomography-guided percutaneous hookwire localization of metallic marker clips in the breast with a radial approach: initial experience

Hookwire localization is the current standard technique for radiological marking of nonpalpable breast lesions. Stereotactic directional vacuum-assisted breast biopsy (SVAB) is of sufficient sensitivity and specificity to replace surgical biopsy. Wire localization for metallic marker clips placed after SVAB is needed. To describe a method for performing computed tomography (CT)-guided hookwire localization using a radial approach for metallic marker clips placed percutaneously after SVAB. Nineteen women scheduled for SVAB with marker-clip placement, CT-guided wire localization of marker clips, and, eventually, surgical excision were prospectively entered into the study. CT-guided wire localization was performed with a radial approach, followed by placement of a localizing marker-clip surgical excision. Feasibility and reliability of the procedure and the incidence of complications were examined. CT-guided wire localization surgical excision was successfully performed in all 19 women without any complications. The mean total procedure time was 15 min. The median distance on CT image from marker clip to hookwire was 2 mm (range 0-3 mm). CT-guided preoperative hookwire localization with a radial approach for marker clips after SVAB is technically feasible.

1180: Interventional procedures on breast disease

One of the most important applications of breast ultrasound is to guide interventional procedures. During this presentation, we will discuss applications, indications, patient preparation, equipment selection, advantages and disadvantages and suggestions that will lead to the most successful results in the use of this procedure using this freehand technique. The main objective of this lecture is to analyse the use in a diagnostic, therapeutic and presurgical stage of the following procedures: fine-needle aspiration; large core biopsy; directional vacuum-assisted biopsy; presurgical localization in nonpalpable lesions. There are two principal approaches for freehand sonographically-guided procedures. One way would be to introduce the needle from the short end of the transducer which will give a clear view of both the needle tip and shaft. The other way would be to introduce the needle from the long axis of the transducer face, having the lesion visualized at its midpoint, with the disadvantage that only the needle point and not the shaft will be seen on screen. There are three fundamental aspects to bear in mind in interventionism: the guidance of the needle into the lesion, the procedure of obtaining the material itself and the cytopathologist’s experience. The main indications for obtaining material in solid lesions with the assistance of Ultrasound are: in tumours suspicious of malignancy, in order to confirm the diagnosis and investigate hormonal receptors and plan the most adequate therapy to apply; in images which do not concur with either the clinical evaluation or mammography results and are suspicious of malignancy; When there is more than one mass where the possibility for multifocal or multicentric malignant disease exists, in order to plan the treatment to follow; in any solid mass of any type, detected in the course of pregnancy or lactation. According to my experience, fine-needle aspiration proves successful with a sensibility of 91%, a specificity of 99.6% and a PPV of 95.8%, being 35% of the total of the lesions evaluated palpable and 65% of them nonpalpable. Core biopsies are made with activated guns using a 14-gauge needle, five passes being necessary in order to obtain enough material from the different areas of the lesion. The advantage of core-biopsy is the possibility to obtain more representative material for the histological evaluation making its accuracy to the final results a 100%. The directional vacuum-assisted biopsy is used in solid lesions bigger than 10 mm, taking only one penetration of the device to obtain several samples of material more representative in volume. For presurgical localization, we use carbon particles or hook-wire as markers, this procedure being successful in 100% of the cases. Conclusion: the importance of all the methods explained above is their role in lesions that are either nonconclusive, those which show doubtful images, in an early diagnosis and in order to avoid unnecessary surgical procedures. The sonographer plays a most important role in the diagnosis of nonpalpable lesions.

A comparison of the accuracy of two minimally invasive breast biopsy methods: a systematic literature review and meta-analysis

The primary objective was to quantify and compare the accuracy and failure rates of directional vacuum assisted biopsy (DVAB) and core needle biopsy (CNB) when used under stereotactic (ST) guidance to biopsy suspicious breast lesions identified with screening mammography. We performed a systematic review of the literature published from January 1996 to July 2004, reporting all-comers populations in Western-style health care systems (i.e., North America, Europe, Australia or New Zealand), referred after screening mammography for breast biopsy using DVAB or CNB under ST guidance. Meta-analyses were conducted for DVAB and CNB, using open surgical biopsy and/or long-term clinical and/or mammogram follow-up as the diagnostic reference standard. The main outcomes of interest were those of greatest clinical relevance, i.e., miss rates and underestimation rates for malignancy. Also, technical failure rate and non-diagnostic rate were assessed for each biopsy method. Thirty-five studies qualified for the review. There were 12 studies with a DVAB group (n=5,119 patients), and 25 studies with a CNB group (n=6,236). There were no studies including both a DVAB and a CNB group, thus precluding any direct, within-study comparisons of accuracy. Overall agreement rate between DVAB and the reference standard was 97.3%, and between CNB and the reference standard, 93.5%. The frequency of technical failures with CNB was slightly higher than DVAB (5.7 vs. 1.5%), as was the frequency of non-diagnostic samples (2.1 vs. 0%). Of the non-diagnostic CNB samples, 23% were subsequently found to be malignant on reference standard. In multivariate analyses using four covariates (procedure type, geographic location, reference standard, and patient position), there were no significant predictors of agreement rates, but some variables were significant predictors of miss rates. For benign to malignant upgrades, study location was a significant predictor, with more upgrades in non-NA locations. For atypia to malignant upgrades, the type of procedure was a significant predictor, with more underestimations in CNB studies. The best available evidence suggests that, in screening populations referred for minimally invasive breast biopsy biopsy requiring ST guidance, DVAB may provide lower miss and underestimation rates for clinically relevant diagnoses than does CNB.

Breast Microcalcifications: Retrieval Failure at Prone Stereotactic Core and Vacuum Breast Biopsy—Frequency, Causes, and Outcome

To retrospectively determine the frequency and causes of failure to retrieve microcalcifications in nonpalpable lesions, as judged on a radiograph of the specimen, and to determine outcome in patients with those lesions. Informed consent was obtained from each patient prior to biopsy. The institutional review board approved this HIPAA-compliant study and granted a waiver of informed consent. Retrospective review was performed of 1701 consecutive nonpalpable microcalcification lesions in 1511 women aged 29-92 years (median age, 54 years) who underwent percutaneous stereotactic biopsy on a prone biopsy table. Biopsy was successively performed with 14-gauge core, 14-gauge vacuum, and 11-gauge vacuum devices, with mild selection bias, and for each lesion, biopsy was performed with one device. Radiographs of the specimen were obtained to see whether microcalcifications were retrieved. Patient, mammographic, and biopsy variables were correlated with negative radiographs of the specimen. At repeat biopsy or mammographic follow-up, outcome was evaluated in patients with benign histologic results and negative radiographs of the specimen by using Fisher exact test P values. Radiographs of the specimen were negative in 16% (30 of 182) of lesions at 14-gauge core biopsy, in 4% (four of 96) of lesions at 14-gauge vacuum biopsy, and in 1% (19 of 1423) of lesions at 11-gauge vacuum biopsy (P < .001). Substantial bleeding was a significant factor (P < .001) in failure to retrieve microcalcifications at only 11-gauge vacuum biopsy. Histologic results in 53 lesions with negative radiographs of the specimen were malignant (n = 6), indicated atypical hyperplasia (n = 6), or were benign (n = 41). Follow-up in patients with 40 benign lesions was performed with repeat biopsy (n = 17, with malignancy in three lesions) or mammography (n = 23) for 15-128 months (median, 70 months); one patient with one lesion was lost to follow-up. Failure to retrieve microcalcifications was least common with 11-gauge directional vacuum-assisted biopsy and occurred in 1% (19 of 1423) of lesions. Cancer was missed in 8% (three of 40) of benign lesions in patients who were followed up.

Papillary Lesions of the Breast: Comparison of the US-guided 14-Gauge Automated Gun Method and the 11-Gauge Directional Vacuum-Assisted Biopsy Method

Papillary Lesions of the Breast: Comparison of the US-guided 14-Gauge Automated Gun Method and the 11-Gauge Directional Vacuum-Assisted Biopsy Method

A minimally invasive biomechatronic approach for breast cancer surgery

This paper presents a novel mechatronic approach for minimally invasive excision of breast tumors along with a pre-defined margin tissue, by extending directional vacuum-assisted biopsy (DVAB) technique. Means of overcoming the limitations of mammotome biopsy probe (by J&J) while adopting it for complete removal of tumor and margin area, which may lead to unpredictable removal of tissue from ill-defined location, are presented. A dual arm robotic system in a hybrid configuration, whereby imaging probe and excision needle can be independently maneuvered, is designed using a modular approach. Two systematic methods for tissue excision viz. the progressive removal and oscillatory removal are proposed and implemented for multiple resections through the target tissue region and ensuring complete removal of the tumor. Collapsing of the tissue after each removal has been taken into consideration while developing the systematic method of tissue removal. System GUI is developed to help the end-users/clinicians for image guidance, target and margin demarcation, on-line update on volume estimation, positioning and controlling the manipulator. A representative number of tissue phantoms were tested to validate the feasibility of the system and proposed concept. The accuracy and repeatability of our present system was measured as ± 0.5 mm and within ± 0.1 mm, respectively.

Sonographically Guided Core Biopsy of the Breast: Comparison of 14-Gauge Automated Gun and 11-Gauge Directional Vacuum-Assisted Biopsy Methods

ObjectiveTo compare the outcomes of 14-gauge automated biopsy and 11-gauge vacuum-assisted biopsy for the sonographically guided core biopsies of breast lesions.Materials and MethodsWe retrospectively reviewed all sonographically guided core biopsies performed from January 2002 to February 2004. The sonographically guided core biopsies were performed with using a 14-gauge automated gun on 562 breast lesions or with using an 11-gauge vacuum-assisted device on 417 lesions. The histologic findings were compared with the surgical, imaging and follow-up findings. The histologic underestimation rate, the repeat biopsy rate and the false negative rates were compared between the two groups.ResultsA repeat biopsy was performed on 49 benign lesions because of the core biopsy results of the high-risk lesions (n = 24), the imaging-histologic discordance (n = 5), and the imaging findings showing disease progression (n = 20). The total underestimation rates, according to the biopsy device, were 55% (12/22) for the 14-gauge automated gun biopsies and 36% (8/22) for the 11-gauge vacuum-assisted device (p = 0.226). The atypical ductal hyperplasia (ADH) underestimation (i.e., atypical ductal hyperplasia at core biopsy and carcinoma at surgery) was 58% (7/12) for the 14-gauge automated gun biopsies and 20% (1/5) for the 11-gauge vacuum-assisted biopsies. The ductal carcinoma in situ (DCIS) underestimation rate (i.e., ductal carcinoma in situ upon core biopsy and invasive carcinoma found at surgery) was 50% (5/10) for the 14-gauge automated gun biopsies and 41% (7/17) for the 11-gauge vacuum-assisted biopsies. The repeat biopsy rates were 6% (33/562) for the 14-gauge automated gun biopsies and 3.5% (16/417) for the 11-gauge vacuum-assisted biopsies. Only 5 (0.5%) of the 979 core biopsies were believed to have missed the malignant lesions. The false-negative rate was 3% (4 of 128 cancers) for the 14-gauge automated gun biopsies and 1% (1 of 69 cancers) for the 11-gauge vacuum-assisted biopsies.ConclusionThe outcomes of the sonographically guided core biopsies performed with the 11-gauge vacuum-assisted device were better than those outcomes of the biopsies performed with the 14-gauge automated gun in terms of underestimation, rebiopsy and the false negative rate, although these differences were not statistically significant.

Stereotactic directional vacuum-assisted breast biopsy in 480 patients with microcalcifications: radiological and pathological correlation

Since 1999 our group started with practical experience on diagnostic use of small, transportable prototypes of high-resolution gamma cameras (patented) for radioguided surgery: the Imaging Probe (IP). First experiences allowed us to develop dedicated prototypes for specific applications. At the moment the most intriguing field is guiding biopsy. Dedicated detectors, characterized by low cost and weight, allow to transfer imaging where the biopsy has to be done. In this paper, a new combined application for breast cancer detection is described. In present system IP is put inside a Fisher digital stereotactic device prepared for Mammotome biopsy: so biopsy can contemporaneously be driven by X-ray stereotaxis and 99mTc-Sestamibi (MIBI) images from IP. The Field Of View (FOV) is about 2×2 cm2 and 0.8 kg weight. This novel scintillation camera is based upon the compact Hamamatsu R7600-00-C8 Position Sensitive Photomultiplier Tube (PSPMT), coupled to scintillating arrays. The PSPMT can be arranged as array when larger FOV is needed.Present application was provided with off line software for image fusion running on the IP dedicated PC. It was matched with the Fisher digital stereotactic X-ray device dedicated to address Mammotome (Ethicon Endo-surgery by Johnson and Johnson) towards breast opacities. Spatial resolution of the IP was 2.5 mm Full-Width Half-Maximum (FWHM) at laboratory tests. A preliminary IP–X-ray digital system inter-calibration was performed using a Perspex-lead phantom. 99mTc MIBI was injected at the dose of 740 MBq 1 h before biopsy to three patients with breast opacities of respectively 0.6, 0.8 and 1.5 cm, scheduled for Mammotome biopsy. Sixty-four pixel scintigraphic images were acquired before and after biopsy in each patient. Operator was allowed to slightly correct the direction of the Mammotome needle taking into account stereotactic X-ray, scintigraphic and fused images. Bioptic samples were also counted with IP before sending them to pathologist.High-resolution IP scintigraphy showed substantial, though not exact, matching between MIBI hot spots and X-ray opacities. More than one hot spot were detected even in the smallest 0.6 cm lesion. Post biopsy scintigraphy showed absence of significant hot spots in two patients, whereas in the third one of the three hot spots still was partially present. All the lesions showed cancer at histological exam. Measurement of radioactivity on biopsy specimens confirmed the heterogeneous distribution of radioactivity within cancers that IP had detected before biopsy. Or study confirms the ability of IP to guide biopsy or anyway to correct X-ray stereotactic drive.