Preoperative Core Biopsy Research Articles

Preoperative prediction of margin requirement following a core biopsy result suggestive of a phyllodes tumour

To determine if imaging features of lesions with a core biopsy suggestive of a phyllodes tumour can be used to identify which lesions require surgical excision with margins. Thirty-one lesions were identified from a prospective database of ultrasound visible masses. Demographic, mammographic, and ultrasound features were assessed while blinded to surgical outcome. Features of those lesions requiring a margin and those that did not were compared. Statistical significance was established using the chi-square test and receiver operating characteristic (ROC) curves. Thirteen lesions (42%) required a margin and 18 lesions (58%) did not. Features found significantly more frequently in those requiring a margin were a poorly defined margin on mammography (7/9 [78%] versus 4/13 [31%]; p=0.04) and at ultrasound, an irregular margin (8/13 [62%] versus 3/18 [17%]; p=0.01), micro-lobulations (7/13 [54%] versus 3/18 [17%]; p=0.028), mixed echogenicity (9/13 [69%] versus 1/18 [6%]; p=0.0002), echogenic clefts (6/13 [46%] versus 1/18 [6%]; p=0.007), posterior enhancement (9/11 [82%] versus 6/18 [33%]; p=0.01), large size (p=0.003) and stiffness at shear-wave elastography (p=0.026). All six screen-detected lesions were benign. There are multiple preoperative features that can be used to guide surgical management of lesions with a preoperative core biopsy result suggestive of a phyllodes tumour.

Preoperative morphological diagnosis of axillary lymph nodes in a breast center consultation service: evaluation of fine-needle aspiration and core biopsy techniques.

Preoperative routine examination of axillary lymph nodes (ALN) in breast cancer patients is carried out physically and by ultrasound imaging; unsuspicious nodes will lead to a sentinel node (SN) procedure, suspicious ones require axillary dissection (AD). Pre-operative biopsy techniques like fine needle aspiration (FNA) or core biopsy (CB) may reduce the number of false "suspicious" cases and prevent overtreatment. We evaluated the effectiveness of both biopsy techniques. After physical and ultrasound examination 241 suspicious ALNs were found in 214 patients. Ultrasound-guided FNA and/or CB procedures were chosen randomly, resulting in 138 FNA and 86 CB. In 17 further events both FNA and CB were employed. The samples were examined in our Cytology lab or in the Pathology Department and the findings correlated with post-operative histological lymph node reports. Patients with histologically proven breast cancer underwent sentinel node biopsy, cytologically or histologically positive FNA/CB-findings prompted ALN dissection. Out of 155 FNA samples 34 were not representative (21.9%), 89 showed no tumor cells (57.4%), 30 showed positive tumor cells (19.4%), leaving two missing. All 103 CB showed representative material, positive in 62 (60.2%) and negative in 41 (39.8%) cases. Correlation with histological reports revealed a statistically non-significant advantage for CB over FNA regarding total accuracy (92.9% vs. 78.3%) and sensitivity (92% vs. 73.7%). Preoperative CB and alternative FNA are valuable complementary methods of predicting ALN involvement in breast cancer patients and may spare the patient unnecessary ALN dissection.

Surgical Management of the Palatal Pleomorphic Adenoma.

Surgical excision is the basic treatment option of the palatal pleomorphic adenoma (PA), it is generally accepted to prevent for recurrence. The purpose of this study was to determine the decision criteria for the management of the palatal PA through evaluating the postoperative results of palatal PA correlation with the clinical appearance. All of patients were evaluated the mucosal ulceration, palatal erosion, and size with CT images in all 18 palatal PAs. The clinical features, surgical methods, and surgical results of these 18 PAs were reviewed. The most common age was 51 to 70 years. One patient was in pediatric age (14 years). Females were involved more commonly than males (F:M ratio was 5:1) Mucosa was normal in 16 patients. Ulcerations of the overlying mucosa were seen in 2 cases. On the coronal CT images, hard palate was erosion in 14 patients who had involved hard palate. The size of tumors was from 7 mm to 33 mm in CT scans. Two patients were ruptured the tumor during the operation, and 1 out of 2 patients was recurred. For the definitive diagnosis is necessary to perform the preoperative core biopsy for the histopathological examination, and CT is necessary for evaluating the erosion of the hard palate and severity of the erosion. Hard palatal PA can be managed by surgical enucleation and removal of the periosteum or involved bone. Soft palatal PA can be managed by surgical enucleation without mucosal resection. Rupture of the tumor is related to the recurrence.

105(PB-006) - Effective use of pre-operative axillary ultrasound and core biopsy can avoid unnecessary sentinel lymph node biopsy procedure

105(PB-006) - Effective use of pre-operative axillary ultrasound and core biopsy can avoid unnecessary sentinel lymph node biopsy procedure

The case for the omission of axillary staging in invasive breast carcinoma that exhibits a predominant tubular growth pattern on preoperative biopsy.

True invasive tubular breast carcinoma (TBC) is unlikely to metastasize to axillary nodes, yet it is routinely subjected to sentinel lymph node biopsy (SLNB), even if the diagnosis was suspected preoperatively. The positive predictive value (PPV) of core biopsy for TBC and the incidence and predictors of axillary metastasis in invasive breast carcinomas identified as tubular-rich on core biopsy are unknown. Prospective patient and tumor data regarding postoperatively confirmed TBCs, and tubular-rich carcinoma identified on preoperative core biopsy between January 2005 and May 2016 was analyzed retrospectively. Axillary metastasis occurred in only 4.2% (4/95) of TBCs, all of which measured >15 mm pathologically. In 11.1% (11/99) of TBCs, the initial core biopsy was either indeterminate/suspicious or ductal carcinoma in situ (DCIS); therefore, their true tubular histotype and size were ascertained following operative excision and before SLNB. Nine were ≤15 mm, and all were node-negative. Only 63.9% (46/72) of tubular-rich core biopsies were confirmed as TBCs; the remaining 36.1% (26/72) were well-differentiated invasive nontubular carcinomas. None of the preoperative patient or tumor features were predictive of true TBC on multivariable analysis; 10.1% (7/69) of carcinomas identified as tubular-rich on core biopsy (regardless of their true histotypes) were node-positive; 23.1% (6/26) in nontubular and 2.3% (1/43) in true tubular carcinomas. Preoperative ultrasound size >15 mm was associated with axillary metastasis in 40.0% (4/10) compared to 5.7% (3/53) in those ≤15 mm (OR = 11.11, 95% CI = 1.99-62.04; multivariable P = .010). Axillary metastasis in TBC is dependent on pathological size; therefore, a case is made for omitting SLNB in small true TBCs confirmed following excision. Preoperative tubular-rich core biopsy is not adequately diagnostic of TBC; however, it selects carcinomas that are well-differentiated, small, and unlikely to metastasize to the axilla, thus allowing for the selective omission of SLNB.

Concordance of DNA methylation profiles between breast core biopsy and surgical excision specimens containing ductal carcinoma in situ (DCIS)

The utility and reliability of assessing molecular biomarkers for translational applications on pre-operative core biopsy specimens assume consistency of molecular profiles with larger surgical specimens. Whether DNA methylation in ductal carcinoma in situ (DCIS), measured in core biopsy and surgical specimens are similar, remains unclear. Here, we compared genome-scale DNA methylation measured in matched core biopsy and surgical specimens from DCIS, including specific DNA methylation biomarkers of subsequent invasive cancer. DNA was extracted from guided 2mm cores of formalin fixed paraffin embedded (FFPE) specimens, bisulfite-modified, and measured on the Illumina HumanMethylation450 BeadChip. DNA methylation profiles of core biopsies exhibited high concordance with matched surgical specimens. Within-subject variability in DNA methylation was significantly lower than between-subject variability (all P<2.20E−16). In 641 CpGs whose methylation was related with increased hazard of invasive breast cancer, lower within-subject than between-subject variability was observed in 92.3% of the study participants (P<0.05). Between patient-matched core biopsy and surgical specimens, <0.6% of CpGs measured had changes in median DNA methylation >15%, and a pathway analysis of these CpGs indicated enrichment for genes related with wound healing. Our results indicate that DNA methylation measured in core biopsies are representative of the matched surgical specimens and suggest that DCIS biomarkers measured in core biopsies can inform clinical decision-making.

Histologic factors predicting invasion in patients with ductal carcinoma in situ (DCIS) in the preoperative core biopsy

BackgroundIt is desirable to decrease the underestimation rate of invasion in cases diagnosed as ductal carcinoma in situ (DCIS) in breast core needle biopsy (CNB) in order to determine the appropriate candidates for axillary staging. The objective of this study is to identify the predictors of invasion in histology. Methods and resultsConsecutive 92 CNB’s were retrospectively evaluated. The upstaging rate was 47.8% after surgery. Among all the evaluated parameters, high nuclear grade, single architectural pattern, marked periductal lymphocytic infiltration, partial myoepithelial loss and the presence of foci suspicious of microinvasion were the significant predictors of invasion (two tailed p values 0.0327, 0.0003, 0.0346, <0.0001, 0.0025; respectively). Variables that didn’t show significant upstaging include: comedo necrosis, microcalcification, periductal fibrosis, various architectural patterns, tumor attenuation, and the immunophenotype. Previous studies were also reviewed. ConclusionsWe identified 5 predictive factors of upstaging. The lack of standardized quantification method may account, at least partially, for the conflicting results in different studies. To overcome this, we suggested a comprehensive reporting template for DCIS identified in CNB.

Radical Nephrectomy for Renal Cell Carcinoma: Its Contemporary Role Related to Histologic Type, Tumor Size, and Nodal Status: A Retrospective Study.

Staging for renal cell carcinoma (RCC) depends on tumor size and the status of the regional lymph nodes. Although lymph node involvement by tumor yields the most accurate staging and prognostic information in patients with carcinomas of various genitourinary organs, the role of lymph node sampling (LNS) in patients with RCC to definitively establish nodal metastases remains unsettled. In this retrospective study of 399 patients with RCC treated by total nephrectomy, 115 cases were subjected to lymph node dissection. The corresponding primary tumors averaged larger than 8 cm. Twenty-nine showed positive lymph nodes (25%). The present review confirms that primary tumor size is a key indicator of nodal involvement. Clear cell and papillary tumors larger than 4 cm involve lymph nodes more commonly than other types of RCC. Sarcomatoid differentiation occurred in all major cell types and existed in numbers too few to predict the likelihood of nodal metastases. LNS in RCC for staging purposes may be warranted based on tumor size (>4 cm) as determined by imaging as well as histologic cell type, the latter suggesting a selective role for preoperative fine needle aspiration or core biopsy.

Iodine-125 seeds to guide removal of impalpable breast lesions: radio-guided occult lesion localization - a pilot study.

The aim of this study was to confirm that radio-guided occult lesion localization using low activity iodine 125 (I-125) seeds (ROLLIS) could be safely and accurately used for localization and guided excision of impalpable breast lesions in different multidisciplinary settings and to prepare staff for a randomized controlled trial. Preoperative image-guided localization of 102 lesions using one or two I-125 seeds with hook-wire back-up was performed in 99 participants at two tertiary hospitals. Preoperative core biopsy in 24 lesions was benign or indeterminate (Group A) and malignant in 78 lesions (Group B). Imaging and histopathology findings and re-excision rates were recorded. Training requirements for new staff and seed handling protocols were refined. All seeds and lesions were successfully removed. In five of 23 Group A participants, malignancy on final pathology required definitive surgery for positive margins. The re-excision rate in Group B was 17%. Overall re-excision rate was 18%. Thirty-seven clinical staff members were trained. Sentinel node localization was successful in all 76 cases. Seeds of low activity were successfully used. The ROLLIS technique using a lower dose (∼2 MBq) seed is safe, effective and can easily be adopted in a large multi-disciplinary setting.

Iodine seed- versus wire-guided localization in breast-conserving surgery for non-palpable ductal carcinoma in situ.

Breast-conserving surgery for isolated non-palpable ductal carcinoma in situ (DCIS) is associated with high rates of incomplete surgical resection in comparison with unifocal invasive breast cancer. Therefore, accurate preoperative localization of the lesion is very important to facilitate adequate resection. Wire-guided localization (WGL) remains the standard for localization of DCIS. Recently, iodine-125 seed-guided localization (I-125 GL) was introduced as an alternative localization technique. The aim of this study was to compare the efficacy of these localization techniques in the resection of DCIS by breast-conserving surgery. Between March 2006 and June 2013, 169 patients with non-palpable DCIS were treated with breast-conserving surgery. Only patients with pure DCIS on both preoperative core biopsy and definitive pathology were included. WGL was performed in 78 patients and I-125 GL in 91 patients. The groups did not differ with respect to age, size of DCIS or type of imaging used. Patients in the I-125 GL group had a significantly lower risk of extensively involved resection margins than those in the WGL group (4 versus 13 per cent respectively; P = 0·048). In patients treated with breast-conserving surgery for non-palpable DCIS, localization with iodine-125 seeds is superior to the WGL technique in reducing the risk of extensively involved resection margins.

Treatment of Giant Fibroadenoma in Young Women: Results after Tumor Excision without Reconstructive Surgery

Introduction: Giant fibroadenoma (GFA) of the breast is defined as fibroadenoma larger than 5 cm, usually presenting unilaterally and manifesting as breast asymmetry or deformity of the breast. Material and Methods: A retrospective database search was done of all patients with giant fibroadenoma who underwent surgery for GFA in the breast center of Hanover Medical School between 2007 and 2014; all patients with GFA were followed up. Data were analyzed with regard to tumor and patient characteristics and esthetic outcome. Results: A total of 13 patients with symptomatic GFA underwent surgery between 2007 and 2014. Mean patient age was 21.2 years (range 14-31 years). In 8 of 13 patients the tumor had resulted in breast deformity and/or breast asymmetry. Average size of the mass was 10.2 cm (range 8.5-12 cm) and average weight was 203.6 g (range 151.2-323.5 g). Initial clinical suspicion of GFA was confirmed by ultrasound examination. Preoperative core biopsy revealed fibroadenoma in 8/13 cases, cellular fibroepithelial lesions with a differential diagnosis of benign phyllodes tumor in 3 cases and unspecific histological findings in the remaining 2 cases. Conclusion: Excision was done using an inframammary or periareolar approach without reconstructive plasty. The cosmetic results were good, as were the outcomes on follow-up. We therefore favor this surgical technique to treat giant fibroadenoma of similar size to those described above.

Intraoperative Frozen Section in Breast Pathology: 10 Years of Experience at an Academic Referral Center

Historically, frozen section procedure has been the routine method of establishing malignancy in the breast, which in turn leads to immediate mastectomy. Excluding axillary sentinel lymph nodes, it is now uncommon to examine frozen sections from breast surgeries. We sought to characterize the role of the frozen section procedure in the current era of preoperative core biopsy by reviewing pathology reports and medical records from …

High tumor budding stratifies breast cancer with metastatic properties.

Tumor budding refers to single or small cluster of tumor cells detached from the main tumor mass. In colon cancer high tumor budding is associated with positive lymph nodes and worse prognosis. Therefore, we investigated the value of tumor budding as a predictive feature of lymph node status in breast cancer (BC). Whole tissue sections from 148 surgical resection specimens (SRS) and 99 matched preoperative core biopsies (CB) with invasive BC of no special type were analyzed on one slide stained with pan-cytokeratin. In SRS, the total number of intratumoral (ITB) and peripheral tumor buds (PTB) in ten high-power fields (HPF) were counted. A bud was defined as a single tumor cell or a cluster of up to five tumor cells. High tumor budding equated to scores averaging >4 tumor buds across 10HPFs. In CB high tumor budding was defined as ≥10 buds/HPF. The results were correlated with pathological parameters. In SRS high PTB stratified BC with lymph node metastases (p ≤ 0.03) and lymphatic invasion (p ≤ 0.015). In CB high tumor budding was significantly (p = 0.0063) associated with venous invasion. Pathologists are able, based on morphology, to categorize BC into a high and low risk groups based in part on lymph node status. This risk assessment can be easily performed during routine diagnostics and it is time and cost effective. These results suggest that high PTB is associated with loco-regional metastasis, highlighting the possibility that this tumor feature may help in therapeutic decision-making.

Upgrade of ductal carcinoma in situ on core biopsies to invasive disease at final surgery: a retrospective review across the Scottish Breast Screening Programme

To identify factors affecting upgrade rates from B5a (non-invasive) preoperative core biopsies to invasive disease at surgery and ways to improve screening performance. This was a retrospective analysis of 1252 cases of B5a biopsies across all six Scottish Breast Screening Programmes (BSPs), ranging between 2004 and 2012. Final surgical histopathology was correlated with radiological and biopsy factors. Data were analysed using basic Microsoft Excel and standard Chi-squared test used for evaluating statistical significance. B5a upgrade rates for the units ranged from 19.2% to 29.2%, with an average of 23.6%. Mean sizes of invasive tumours were small (3-11 mm). The upgrade rate was significantly higher for cases where the main mammographic abnormality was mass, distortion, or asymmetry, compared with micro-calcification alone (33.2% versus 21.7%, p = 0.0004). The upgrade rate was significantly lower with the use of large-volume vacuum-assisted biopsy (VAB) devices than 14 G core needles (19.9% versus 26%, p = 0.013); in stereotactic than ultrasound-guided biopsies (21.2% versus 36.1%, p < 0.001). Heterogeneity of data from different centres limited evaluation of other potential factors. Upgrade rates are lower for cases with micro-calcification as the sole mammographic feature with the use of VAB devices. Nevertheless, there is variation in practice across Scottish BSPs, including first-line biopsy technique and/or device; and it is of interest that a few centres maintain low upgrade rates despite not using VAB routinely for biopsy of micro-calcification.

The role of ultrasound guided core biopsy of axillary nodes in predicting macrometastases and avoiding overtreatment outside ACOSOG Z0011 parameters

BackgroundZ0011 study suggests patients with minimal disease do not require axillary clearance. Exclusions include T3 tumours, mastectomy or neoadjuvant treatment. This study assessed the utility of pre-operative US-guided core biopsy of axillary nodes and its correlation with nodal macrometastases. Methods247 women with breast cancer outside Z0011 criteria were reviewed retrospectively. Sensitivity and specificity of pre-operative axillary ultrasound and core biopsy compared to final histology was assessed by contingency tables. Results75/247 patients had macrometastases. Ultrasound-axilla was 72% sensitive and 77% specific in predicting macrometastasis. The positive (PPV) and negative predictive value (NPV) was 58% and 86.4% respectively. Core-biopsy of axilla node, was 92.6% sensitive and 66.7% specific in detecting macrometastasis. PPV and NPV 79.4% and 86.7% respectively. ConclusionPositive pre-operative ultrasound-guided core biopsy accurately predicts macroscopic involvement of axillary nodes. Selected patients outside Z0011 parameters can proceed to axillary clearance without sentinel node biopsy or risking overtreatment.

167. Immune checkpoints in breast cancer surgery

167. Immune checkpoints in breast cancer surgery

169. Can lymphovascular invasion detected in preoperative core biopsy predict sentinel node positivity in early breast cancer?

169. Can lymphovascular invasion detected in preoperative core biopsy predict sentinel node positivity in early breast cancer?

Survey of American and Canadian general surgeons' perceptions of margin status and practice patterns for breast conserving surgery.

Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.

Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario

Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario. Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region. Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons. This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

The implementation of a surgeon-directed quality improvement strategy in breast cancer surgery

BackgroundThe investigators designed a sustained, surgeon-directed, iterative project to improve the quality of breast cancer surgery in south central Ontario. MethodsThe strategy included audit and feedback of surgeon-selected quality indicators, workshops, and tailoring interviews. Workshops were held to discuss quality improvement strategies, select quality indicators, review audited results, and select interventions for subsequent implementation. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All presentations and results were disseminated to all surgeons performing breast surgery in the study region. ResultsForty-four surgeons performing breast surgery across 12 hospitals are involved in the project. Five workshops have been held since 2005. Surgeons' enthusiasm and involvement in the project have been positive. Interim results demonstrated that over 4 audit cycles (2006–2010), the preoperative core biopsy rate increased from 73% to 92%. The tailoring interviews indicated that 18 of 21 surgeons performed preoperative core biopsies. ConclusionsThis project highlights the feasibility of a surgeon-directed, iterative quality improvement strategy in breast cancer surgery. Interim results demonstrate consistent improvements in a key selected quality indicator.