Stereotactic Core Needle Biopsy Research Articles

Does Exhaustive Search for Microcalcifications Improve Diagnostic Yield in Stereotactic Core Needle Breast Biopsies?

Stereotactic core needle biopsy (SCNB) of the breast is a cost-effective alternative to needle localization biopsy for the diagnosis of mammographic calcifications. We questioned whether an exhaustive search for calcium in the small samples obtained in SCNB yields more diagnostic information than that obtained with examination of a standard number of sections. We retrospectively reviewed 168 specimens from 123 patients with mammographic calcifications, including cases in which radiographic suspicion ranged from low to high. Microcalcifications were identified on three initial levels in 112 specimens. Additional sections were examined in 50 specimens. The final diagnosis differed from the diagnosis based on three levels in 11/50 cases (22%). In 6/50 (12%), complete sectioning yielded a specific diagnosis. The increase in technical cost associated with the additional levels was 414% per case. We conclude that exhaustive searching for microcalcifications in SCNB yields a small increase in specific diagnostic information and a high technical cost. In individual cases, the additional information may be critical for appropriate patient management.

Local Recurrence of Breast Cancer in the Stereotactic Core Needle Biopsy Site: Case Reports and Review of the Literature

Early mammographic detection of nonpalpable breast lesions has led to the increasing use of stereotactic core biopsies for tissue diagnosis. Tumor seeding the needle tract is a theorectical concern; the incidence and clinical significance of this potential complication are unknown. We report three cases of subcutaneous breast cancer recurrence at the stereotactic biopsy site after definitive treatment of the primary breast tumor. Two cases were clinically evident and relevant; the third was detected in the preclinical, microscopic state. All three patients underwent multiple passes during stereotactic large-core biopsies (14 gauge needle) followed by modified radical mastectomy. Two patients developed a subcutaneous recurrence at the site of the previous biopsy 12 and 17 months later; one had excision of the skin and dermis at the time of mastectomy revealing tumor cells locally. In summary, clinically relevant recurrence from tumor cells seeding the needle tract is reported in two patients after definitive surgical therapy (without adjuvant radiation therapy). Often, the biopsy site is outside the boundaries of surgical resection. Since the core needle biopsy exit site represents a potential area of malignant seeding and subsequent tumor recurrence, we recommend excising the stereotactic core biopsy tract at the time of definitive surgical resection of the primary tumor.

Stereotactic core-needle breast biopsy: a multi-institutional prospective trial.

To assess the accuracy of stereotactic core-needle biopsy (CNB) of nonpalpable breast lesions within the context of clinically important parameters of anticipated tissue-sampling error and concordance with mammographic findings. CNB was performed in 1,003 patients, with results validated at surgery or clinical and mammographic follow-up. Mammographic findings were scored according to the American College of Radiology Breast Imaging Reporting and Data System with a similar correlative scale for histopathologic samples obtained at either CNB or surgery. Agreement of CNB findings with surgical findings or evidence of no change during clinical and mammographic follow-up (median, 24 months) for benign lesions was used to determine results. Three forms of diagnostic discrimination measures (strict, working [strict conditioned by tissue sampling error], applied [working conditioned by concordance of imaging and CNB findings) were used to evaluate the correlation of CNB, surgical, and follow-up results. Strict, working, and applied sensitivities were 91% +/- 1.9; 92% +/- 1.8, and 98% +/- 0.9, respectively; strict, working, and applied specificities were 100%, 98% +/- 0.8, and 73% +/- 0.9; strict, working, and applied accuracies were 97%, 96%, and 79%. Percutaneous stereotactic CNB is an accurate method to establish a histopathologic diagnosis of nonpalpable breast lesions. Accuracy increases when additional surgery is performed for lesions with anticipated sampling error or when CNB findings are discordant with mammographic findings. An understanding of the interrelationship among these parameters is necessary to properly assess results.

Metallic clip deployment during stereotactic breast biopsy: retrospective analysis.

To determine the visibility of presumably excised lesions on screen-film mammograms obtained after biopsy and to determine the accuracy of clip deployment on the basis of measurements obtained on routine pre- and postbiopsy mammograms. One hundred eleven cases of core-needle biopsy with clip deployment were reviewed. In each, the type of lesion, lesion location, and biopsy approach were recorded. Pre- and postbiopsy images were reviewed, and the distance between the clip and biopsy site was measured. Postbiopsy images were reviewed to determine whether the targeted lesion remained visible. In 62 (56%) cases, the clip was located within 5 mm of the target on postbiopsy images (craniocaudal and mediolateral), while in 18 (16%), the clip was within 6-10 mm on one projection. However, 31 (28%) clips were more than 1 cm from the target on at least one postbiopsy image. Of the 111 cases, 39 (35%) were malignant or atypical and required excision. Of these, 18 (46%) had clips at least 1 cm from the targeted lesion on at least one projection. Metallic clips placed during core-needle breast biopsy are intended to mark the biopsy site when the visible lesion is excised, in case additional biopsy is required. The data suggest that the position of metallic clips placed during stereotactic core-needle biopsy may differ substantially from the location of the biopsy site. Postbiopsy mammography should be performed in two orthogonal planes to document clip position relative to the biopsy site.

Rentabilidad de la biopsia con aguja gruesa guiada mediante estereotaxia en el estudio de calcificaciones mamarias

ObjectiveTo determine the utility of stereotactic core needle biopsy in the study of breast calcifications. Material and methodsWe performed a retrospective study of 71 women who had undergone stereotactic biopsy and surgical biopsy after mammography had revealed the presence of calcifications. All radiologic images were subjected to double reading and the calcifications were classified as categories 3, 4 or 5 according to the Breast Imaging Reporting and Data System (BI-RADS). ResultsOf the 71 patients, in 19 the lesions were classified as category 3, in 30 as category 4 and in 22 as category 5. Core needle biopsy revealed carcinoma in 30 cases, atypical ductal hyperplasia in 8, a complex sclerosing lesion in 1 and benign lesions in 32, 14 of which were shown by surgical biopsy to be false negatives. Core needle biopsy had a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 75% in category 3 calcifications, while in categories 4 and 5, the PPV was 90.62% and the NPV only 42.85%. ConclusionsCore needle biopsy is a useful tool to indicate the suitability of radiologic follow-up or the need for surgical biopsy in category 3 lesions. In lesions corresponding to categories 4 and 5, the utility of this technique is more limited, although it aids in planning the surgical procedure. Surgical biopsy should be carried out in all cases in which core needle biopsy reveals the presence of atypical ductal hyper-plasia or carcinoma in situ.

Long-Term Outcomes of Stereotactic Breast Biopsies

Stereotactic core needle biopsies (SCNBs) are accurate and relatively convenient for the patient; however, the long-term follow-up of benign results has not been reported. All patients between 1993 and 1998 undergoing SCNB at a community-based hospital were entered into a registry. Follow-up was obtained by a retrospective analysis of the charts. Biopsies were performed on 865 lesions. One hundred thirty-one (15%) were malignant, 42 (5%) were suspicious for malignancy, 687 (79%) were benign, and five (1%) were lobular carcinoma in situ. Of the 42 patients with suspicious findings 38 underwent biopsy. Ten were malignant and 28 benign. Of the 687 patients with benign pathology, 377 had follow-up available with a mean length of 1.7 years. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SCNB for benign lesions in our study are all 100 per cent. Eight lesions were worrisome and await final analysis. Of 687 patients with benign lesions 310 were lost to follow-up. This study suggests that patients with a benign diagnosis should be returned to routine mammography. These data also extend the reported follow-up to 1.7 years and establish an acceptable level of accuracy for SCNB. The lost patients remind us that follow-up is essential despite a benign diagnosis.

Ductal carcinoma in situ diagnosed with stereotactic core needle biopsy: can invasion be predicted?

To determine whether mammographic or histologic features can be used to predict which cases diagnosed as ductal carcinoma in situ (DCIS) without invasion by means of stereotactic core needle biopsy (SCNB) will have invasive disease at surgery. From July 1992 to March 1999, DCIS without invasion was diagnosed by means of SCNB in 59 patients. Seventeen (29%) were found to have invasive disease after surgery. The underestimation rate for SCNB was compared with that obtained by means of open surgical biopsy. Mammographic and histologic features of cases with and those without invasion were compared. All patients had calcifications on mammograms. There was no significant difference (P: =.26) between the underestimation rate for SCNB with the 11-gauge vacuum-assisted device and that for open surgical biopsy. No statistically significant differences between cases with and those without invasion were seen in patient age, mean number of core specimens, level of suspicion, size of lesion, distribution and morphology of the calcifications, presence of an associated mass or density, subtype of DCIS, nuclear grade, or presence of necrosis or desmoplasia. Mammographic and histologic features cannot be used reliably to predict cases that are underestimated with SCNB. However, SCNB with the 11-gauge vacuum-assisted device was as reliable as open surgical biopsy for diagnosing DCIS without invasion.

Stereotactic core-needle breast biopsy by surgeons: minimum 2-year follow-up of benign lesions.

To evaluate the reliability of stereotactic core-needle breast biopsy (SCNB) performed by surgeons to detect histologically benign tissue. Stereotactic core-needle breast biopsy is widely used to obtain tissue for definitive pathologic diagnosis of mammographically suspicious breast lesions. It has an incidence of malignancy detection similar to that of open biopsy. The potential for sampling error is a concern. Minimal data regarding follow-up and failure rate are available, especially from series performed exclusively by surgeons. Pertinent medical records of all patients who underwent SCNB between April 1995 and October 1997 were reviewed. Breast lesions were classified by mammographic Breast Imaging-Reporting and Data Systems (BI-RADS) categories before SCNB. Benign biopsy specimens were classified as nonproliferative or proliferative. Malignant lesions and those with atypical histopathology by SCNB were excluded from this analysis. All lesions initially reported as benign were followed up mammographically for at least 2 years for any suspicious change requiring repeat biopsy. During the 31-month period, SCNB was performed on 694 lesions in 619 patients. Histologic evidence of malignancy was found in 112 lesions (16%). The initial histologic diagnosis for the remaining 582 lesions was benign. Four hundred lesions were available for follow-up; of these, 373 (93%) were mammographically categorized as BI-RADS 3 (probably benign) or 4 (suspicious). Three hundred forty-three lesions were categorized as nonproliferative and 151 as proliferative (94 had combined nonproliferative and proliferative histology). Follow-up ranged from 24 to 48 months (mean 33 months). During the follow-up period, 87 lesions (21.8%) underwent either image-guided or open biopsy. At the time of follow-up rebiopsy, ductal carcinoma in situ was found in four lesions and infiltrating ductal carcinoma was found in one, for an overall false-negative rate of 4.3% (5/117) and a negative predictive value of 98.8% (395/400). For the five false-negative cases, the interval from initial SCNB to definitive diagnosis ranged from 7 to 36 months. No correlation was found between the type of initial histopathology and development of malignancy. These results support SCNB as an alternative to open biopsy and show the reliability of SCNB when benign pathology is obtained. However, given the possibility of sampling error and the nature of breast disease, close mammographic and clinical follow-up is necessary. The false-negative rate and negative predictive value in this series compare favorably with those in other reports, supporting the fact that surgeons can confidently use SCNB in the evaluation and treatment of breast disease.

Uncommon high-risk lesions of the breast diagnosed at stereotactic core-needle biopsy: clinical importance.

To assess the outcome of papillary lesions, radial scars, or lobular carcinoma in situ (LCIS) diagnosed at stereotactic core-needle biopsy (SCNB). Retrospective review of 1,236 lesions sampled with SCNB yielded 22 papillary lesions, nine radial scars, and five LCIS lesions. Diffuse lesions such as papillomatosis, papillary ductal hyperplasia, papillary ductal carcinoma in situ (DCIS), and atypical lobular hyperplasia were not included. The mammographic findings, associated histologic features, and outcome were assessed for each case. Sixteen papillary lesions were diagnosed as benign at SCNB. Of these, five were benign at excision, and 10 were unremarkable at mammographic follow-up. At excision of an unusual lesion containing a microscopic papillary lesion, DCIS was found. Three of four papillary lesions suspicious at SCNB proved to be papillary carcinomas; the fourth had no residual carcinoma at excision. Eight of nine radial scars were excised, which revealed atypical hyperplasia in four scars but no malignancies. One LCIS lesion was found at excision to contain DCIS. Benign or malignant papillary lesions were accurately diagnosed with SCNB in the majority of cases. Cases diagnosed as suspicious for malignancy or with atypia or unusual associated histologic findings should be excised. No malignancies were found at excision of radial scars diagnosed at SCNB. Surgical removal of these lesions following SCNB may not be routinely necessary. DCIS was found in one lesion diagnosed as LCIS at SCNB, which suggests that removal of these lesions may be prudent.

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

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. Retrospective medical record and histopathologic review. University-based academic practice setting. 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. Correlation between stereotactic biopsy histologic results and the histologic results of subsequent surgical specimens. 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. 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.

The diagnosis and management of ductal carcinoma in-situ of the breast.

The widespread utilization of screening mammography has produced a shift in the stage of breast cancer at diagnosis in the US: Currently, 12% to 15% of newly diagnosed breast cancer cases annually are ductal carcinoma in-situ (DCIS). The diagnosis is made, in at least 90% of patients, with mammography. Only about 10% of patients will have a palpable mass. The accurate characterization and visualization of calcifications typically requires magnification of mammographic imaging. The morphology of the calcifications is generally considered to be the most important factor in differentiating benign from malignant formations. Round and uniform shapes are more likely to be benign, while linear and heterogeneous morphologies are associated with DCIS. Following a complete mammographic work-up, most suspicious lesions are potential candidates for a stereotactic core needle biopsy. Ten percent to 50% of patients initially diagnosed with atypical ductal hyperplasia by needle biopsy have subsequently been surgically diagnosed with cancer near the biopsy site. Due to this relatively high incidence of co-existent carcinoma, a needle biopsy diagnosis of atypical ductal hyperplasia necessitates subsequent surgical excision. The most important change in our thinking about DCIS was from a monolithic view, conceiving of DCIS as a single disease highly likely to invade if left untreated, to the realization that DCIS represents a non-obligate precursor with a variable risk of progression, depending on a combination of factors, such as histology, lesion, size, and margin status. In discussing treatment options, patients should understand that local recurrence following total mastectomy is rare and that this is the procedure of choice for disease that cannot be adequately encompassed with a breast-conserving approach. If the patient and her surgeon are in agreement about proceeding with a breast-conserving approach, there needs to be a clear understanding of the incidence and implications of local recurrence. In all such discussions with newly diagnosed patients, however, it is essential to emphasize the excellent prognosis with this disease, irrespective of the surgical approach.

Follow-up of benign results of stereotactic core breast biopsy

The purpose of this study was to obtain long-term follow-up data on women with benign histologic results of a breast stereotactic core needle biopsy (CNB). Mammography charts of 300 consecutive women who underwent prone stereotactic CNB with digital radiography were reviewed. Women with frankly malignant or suspicious histologic findings (51 patients) or a technically unsuccessful stereotactic CNB (one patient) were excluded. The remaining 248 benign core biopsies in 229 women were included in the study. Follow-up mammograms were obtained for 152 lesions with benign histologic results following stereotactic CNB. The mean length of follow-up after stereotactic CNB was 34.6 months. Cancer was diagnosed in six women who underwent surgical biopsies 1/2 to 30 months after benign stereotactic CNB. An initial chart review demonstrated that no follow-up data were available for 64 lesions, and information was missing for an additional seven. SCNB remains a sampling procedure that can result in false-negative histologic results. Intrinsic procedural issues were identified that could minimize the potential for missing a malignancy. Goals for patient compliance with follow-up recommendations fell short of expectations.

PRE-OPERATIVE SIMULTANEOUS STEREOTACTIC CORE BIOPSY AND FINE-NEEDLE ASPIRATION BIOPSY IN THE DIAGNOSIS OF INVASIVE LOBULAR BREAST CARCINOMA

To determine the diagnostic value of stereotactic core needle biopsy (SCNB) in comparison to stereotactic fine-needle aspiration biopsy (SFNAB) in patients with invasive lobular carcinoma (ILC). Twenty-two patients with clinical or mammographic findings suspicious of malignancy underwent surgery where postoperative histopathology showed ILC. Pre-operative attempts of diagnosis were made using SFNAB and SCNB. SFNAB was done with a spinal needle 0.7- or 0.9-mm and SCNB was simultaneously performed with an automated 2.1-mm biopsy gun in all patients. SFNAB was diagnostic of carcinoma in 9 women, showed "probable carcinoma" in 5 and "atypia" in 3. In the remaining 5 women, SFNAB showed no atypia. SCNB diagnosed ILC in 20 patients and showed ILC as well as invasive ductal carcinoma (IDC) in 1. Ductal carcinoma in situ was suggested in the remaining patient. SCNB was superior to SFNAB in diagnosing ILC and did not miss any carcinoma, whereas SFNAB was non-diagnostic in 8 cases. SCNB is thus recommended in patients with suspicion of ILC of the breast.

Pre-operative simultaneous stereotactic core biopsy and fine-needle aspiration biopsy in the diagnosis of invasive lobular breast carcinoma

Purpose: To determine the diagnostic value of stereotactic core needle biopsy (SCNB) in comparison to stereotactic fine-needle aspiration biopsy (SFNAB) in patients with invasive lobular carcinoma (ILC). Material and Methods: Twenty-two patients with clinical or mammographic findings suspicious of malignancy underwent surgery where postoperative histopathology showed ILC. Pre-operative attempts of diagnosis were made using SFNAB and SCNB. SFNAB was done with a spinal needle 0.7- or 0.9-mm and SCNB was simultaneously performed with an automated 2.1-mm biopsy gun in all patients. Results: SFNAB was diagnostic of carcinoma in 9 women, showed “probable carcinoma” in 5 and “atypia” in 3. In the remaining 5 women, SFNAB showed no atypia. SCNB diagnosed ILC in 20 patients and showed ILC as well as invasive ductal carcinoma (IDC) in 1. Ductal carcinoma in situ was suggested in the remaining patient. Conclusion: SCNB was superior to SFNAB in diagnosing ILC and did not miss any carcinoma, whereas SFNAB was non-diagnostic in 8 cases. SCNB is thus recommended in patients with suspicion of ILC of the breast.

Follow-up of breast lesions diagnosed as benign with stereotactic core-needle biopsy: frequency of mammographic change and false-negative rate.

To determine how often lesions diagnosed as benign with stereotactic core-needle biopsy (SCNB) change at follow-up mammography and to determine the optimal follow-up strategy and the delayed false-negative rate. From July 1992 through December 1995, 355 of 540 cases (66%) in which SCNB yielded benign results were managed with follow-up mammography. Mammographic follow-up was available for 298 of these cases (84%). Follow-up mammography reports were reviewed. When a change was reported, pre- and postbiopsy mammograms, pathology reports, and results of subsequent mammographic follow-up were reviewed. Mammographic change occurred in 21 of 298 cases (7%) at intervals of 6-55 months (mean, 20 months). Change occurred after initial mammographic stability in 10 of 21 cases. Repeat biopsy was performed in 18 of 21 cases. Malignancy was diagnosed in two cases: one mass that changed at 6 months and one case of microcalcifications that changed at 24 months. This represented a delayed false-negative rate of 2% (two of 105 malignancies among 540 biopsies). A small percentage of cases diagnosed as benign with SCNB will change on follow-up mammograms, which may necessitate repeat biopsy. These results suggest that 6-month follow-up for cases that yield nonspecific benign results at SCNB and yearly screening mammography for cases with specific benign results is a reasonable management strategy.

Follow-up After Benign Stereotactic Breast Biopsy

Stereotactic core-needle biopsy (SCNB) can be used to evaluate mammographically detected breast lesions that are not palpable. These researchers from Yale determined outcomes for 298 women who had mammographic follow-up after a benign SCNB. The SCNB diagnosis was a nonspecific benign result in …

The evolving practice pattern of the breast surgeon with disappearance of open biopsy for nonpalpable lesions

Background: Recent advances in technology have prompted growth in the surgeon’s armamentarium for breast biopsy. For nonpalpable, mammographically detected lesions, the options include stereotactic needle/wire localization and open biopsy (SNL/OBx), stereotactic needle core biopsy (SNCB), and directional, vacuum-assisted biopsy (VAB; Mammotome). Methods: A review of 372 patients with 424 breast lesions biopsied by the same surgeon between January 1993 and August 1997 was performed. Results: SNCB and VAB procedures were less invasive and less morbid than SNL/OBx. Vacuum-assisted biopsy was superior to SNCB for sampling efficiency, with 74% of microcalcifications removed compared with 20% ( P <0.0001). Additionally, underestimation of disease was seen with the SNCB technique, but not with VAB. Follow-up mammography found no false negative biopsies in any group. Over the 56 consecutive months, VAB progressively replaced SNL/OBx and SNCB as the procedure of choice. Conclusion: A breast surgeon can use VAB to replace open biopsy and core needle procedures for the initial biopsy of nonpalpable breast lesions.

Breast Conservation from the Standpoint of a Pathologist:Diagnostic Issues of Stereotactic Needle Core Biopsy.

Breast Conservation from the Standpoint of a Pathologist:Diagnostic Issues of Stereotactic Needle Core Biopsy.

Accuracy of stereotactic core-needle breast biopsy in atypical ductal hyperplasia

The histologic diagnosis of atypical ductal hyperplasia (ADH) has been reported as having a high rate of malignancy, either ductal carcinoma in situ (DCIS) or invasive ductal carcinoma (IDC). We reviewed our surgical group's experience with stereotactic core-needle biopsies (SCNB), specifically looking at the follow-up of ADH. From November 1994 through July 1997 our group performed 539 SCNB. Twenty-one patients (4%) were diagnosed as ADH. Eighteen patients had subsequent wire-localized excisional biopsies. Three patients were followed up mammographically. One patient refused follow-up. Of the 18 patients who underwent excisional biopsies, 2 patients were found to have DCIS and 1 patient had lobular carcinoma in-situ. There were no cases of IDC. Our results show a much lower incidence of malignancy in cases of ADH found on SCNB than has been previously reported. While the standard of care is still to follow up ADH found on SCNB with excisional biopsy, more data may justify following up certain subsets of patients.

Surgeons and Interventional Radiologists: Doing What’s Best for the Patient

Opportunities have broadened for the early detection and cure of early stage breast cancer through screening mammography. The gains realized may be offset by overinterpretation of mammographic abnormalities, leading to an excessive number of breast biopsies. This is particularly true in an era of emerging technology, such as stereotactic core needle biopsy. Other than overuse, the major issues to be discussed in this report include a review of the currently available information on this technology, especially as it relates to accurately diagnosing breast cancer, an analysis of the training and experience characteristics necessary for physicians to perform the procedure, the collaboration of the American College of Surgeons, the American College of Radiology, and the College of American Pathologists to set national standards, and the credentialing of physicians performing stereotactic core needle biopsy of the breast. The guiding principle in all these deliberations has been to keep quality patient care in perspective rather than placing the patient in the middle of potential conflict between physicians from different specialties.