Vacuum Biopsy Research Articles

B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update

B3lesions of the breast are aheterogeneous group of lesions with uncertain malignant potential encompassing abroad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass aspectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.

Breast Amyloidosis: A Case Report and Literature Review.

Amyloidosis is an uncommon disorder characterized by extracellular accumulation of misfolded proteins in tissues. We report a unique case of localized breast amyloidosis in an asymptomatic 56-year-old woman with systemic lupus erythematosus, presented as suspicious microcalcifications without mass on mammography. Vacuum biopsy confirmed amyloidosis, producing the typical apple-green birefringence under polarized light after staining with Congo-red. Further workup and follow-up to exclude development into systemic amyloidosis or hematologic malignancy is recommended. If negative, the prognosis is very good, thus no further treatment is needed. A brief review of the literature revealed more about the typical findings and recommended management.

Evaluation of Real-world Data for Breast-MRI BI-RADS IV Lesions.

Magnetic resonance imaging (MRI) is an important diagnostic tool in the detection of breast cancer. The Breast Center of the municipal Hospital Holweide, Cologne, annually cares for and treats patients with changes in the breast. A special problem is posed by Breast Imaging-Reporting and Data System (BI-RADS) 4 lesions. If a BI-RADS 4 finding is present, is a vacuum biopsy indicated in every case or, if there is already an indication for surgery due to other findings, can the corresponding finding be removed openly without histological clarification? We require real world data regarding the actual in-center likelihood of a BIRADS 4 lesion to be DCIS (Ductal carcinoma in situ) or invasive disease. This is a retrospective study of 1,641 patients who received MRI examination in the radiological department of the municipal hospital Holweide in 2012 and 2013. Each BI-RADS 4 finding (or higher) classified by MRI was compared with the final histological result. 347 MRIs showed BI-RADS 4 findings or higher and 280 (80.7%) cases showed benign histology. In 67 (19.3%) cases, histology showed DCIS or invasive carcinoma. BI-RADS 4 lesions have a low probability of malignancy based on real-world data from this center. If there is already an indication for surgery due to other lesions, the patient can also be offered a simultaneous open biopsy in the context of the already initiated surgical treatment. Each center should know the sensitivity and specificity of the MRI imaging performed and counsel patients based on that.

P086. Novel pulse biopsy platform incorporating adaptive open-tip sampling needle increases sampling yield and needle control

Introduction: Certain lesions are challenging to reach and target, e.g. axillary lymph nodes. A novel biopsy platform, NeoNavia (NeoDynamics, Sweden), incorporates a pneumatic needle insertion mechanism intended to provide better control of needle progression. It offers a 14G automated core needle (CorePulse), 10G vacuum biopsy needle (VacuPulse) and newly developed adaptive 14G open-tip sampling needle (FlexiPulse). Sampling yield of the 14G open-tip needle was benchmarked against a currently used device in a turkey tissue model and needle velocity was measured.

Vacuum-assisted breast biopsy of microcalcifications on the stereotactic prone table and comparison of the histopathologic diagnosis with mammographic features

Aim: Breast cancer is one of the most important causes of mortality and morbidity in women. With the widespread use of screening mammography, the detection of non-palpable suspected cancerous lesions is increasing. Therefore, the use of vacuum-assisted breast biopsy in the management of breast lesions continues to increase. The aim of this study was to evaluate the histopathological results of suspicious microcalcifications which were diagnosed by vacuum-assisted needle biopsy on a stereotactic prone table and to compare the mammographic features of the microcalcifications with the histopathological results. Materials and Methods: The study included a total of 119 patients with a median age of 51 years (range, 33-77 years) who underwent stereotactic biopsy on a prone table because of suspicious microcalcifications between March 2010 and July 2014. Retrospective evaluation was made of the preoperative mammographic features, and the BI-RADS (Breast imaging-reporting and data system) scores of the microcalcifications and the vacuum biopsy and / or excisional histopathological results. Results: Stereotactic vacuum-assisted breast biopsy revealed that 52.1% of the lesions were benign and 47.9% were malignant. After vacuum-assisted stereotactic biopsy 61 patients underwent surgery. In 10 of these (16.3%) the final excisional histopathological diagnosis was benign, and in 51 (83.7%) malignancy was determined. Conclusion: Vacuum-assisted breast biopsy on a stereotactic prone table is a successful technique with a low failure rate for microcalcifications that are non-palpable and have no ultrasonographic findings.

Abstract LB-273: First clinical validation of the physical biomarker based on the nanomechanical tissue profiling for rapid breast cancer diagnosis, prognosis and predication of treatment outcome

Abstract Clinical treatment of breast cancer is successful. What remains a challenge for individualized therapy is the prediction of which cancer responds to which treatment. Emerging evidence indicates that mechanical alterations on a (sub-) cellular level are markers of cancer aggressiveness. Detecting these could serve as biomarker and help optimize cancer diagnosis, therapy choice, and patient follow-up. We developed a diagnostic platform called ARTIDIS (Automated and Reliable Tissue Diagnostics) based on atomic force microscopy (AFM)-type nanomechanical testing. ARTIDIS uses a 20-nanometer-sharp tip measuring 10'000 miniscule indentation across the biopsy's surface and quantifies stiffness on a molecular level. The relative size and distribution of stiffness values is integrated into a data analytics tool that systematically analyses tissue biomechanics in correlation to clinical parameters, histological prognostic markers, and treatment yielding prognostic and predictive value. To demonstrate ARTIDIS' clinical utility for diagnosis and development of prognostic and predictive biomarkers we conducted a prospective blinded clinical study on 545 patients. All patients undergoing a core needle or vacuum biopsy of the breast qualified. Within the routine clinical workflow, ARTIDIS analyzed fresh biopsies in a physiological solution preserving the biopsy's viability for histological and genetic analysis. Per patient, one representative biopsy was measured, marked and reunited with the patient's other biopsies for standard histological procedure. In total, 583 biopsies from N=545 patients were analyzed: 62.1% were B1-B4 (normal, benign, of uncertain malignant potential, or suspicious); a third (36.9%) malignant (B5a-B5d), and six specimens (1%) not assignable. Half of all B5b lesions were Luminal B, followed by Luminal A, Luminal B-like, HER2-positive or triple negative. The analysis of the primary endpoint (N=520 patients qualified, N=3 were excluded due to missing information) demonstrated ARTIDIS' ability to detect cancer in all samples including lesions with <5% neoplastic tissue: diagnostic ROC curve of B1+B2 lesions vs. all B5 lesions (CI 95%; 96% sensitivity, 78% specificity, AUC = 0.94) . Secondary endpoints were evaluated and included ARTIDIS' ability to distinguish and further categorize molecular subtypes of breast cancer. We could separate more aggressive cases within the Luminal B subtype (CI 95%; sensitivity 83%, specificity 82%, AUC = 0.86). Secondary analysis also indicated a similarity between the majority of B3 (uncertain) and B2 (benign) lesions and distinct differences from all B5a and B5b, which could help reduce overtreatment of B3 lesions. This large prospective single center study demonstrated ARTIDIS' ability to differentiate benign from malignant lesions and to further subclassify specific breast cancer subtypes. In addition, Luminal B cancers exhibited nanomechanical profiles associated with better or worse prognosis and treatment outcome. The final analysis results provide cutoffs that will be assessed in the upcoming large multicenter prospective trial. Finally, this study helped to determine clinical utility of nanomechanical characterization of breast and other solid cancers for prediction and treatment optimization. Citation Format: Rosemarie Burian, Ahmed Jizawi, Flora Scott, Sabine Schädelin, Christian Raez, Simone Muenst-Soysal, Tatjana Vlaijnic, Ellen Obermann, Sophie Dellas, Serafino Forte, Zlatko Marušić, Tobias Appenzeller, Philipp Oertle, Nam Seung-Zln, Gregory Zaugg, Milan Liepelt, Gabriel Zihlman, Roderick Lim, Marko Loparic, Marija Plodinec. First clinical validation of the physical biomarker based on the nanomechanical tissue profiling for rapid breast cancer diagnosis, prognosis and predication of treatment outcome [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-273.

Atypical Lesions of the Breast and Lobular Carcinoma in Situ in Pregnancy - Surgeons' Practice.

Approach to precancerous and high-risk breast lesions occurring in pregnancy has received little attention in the literature. We carried out a study to investigate the practice of surgeons in the management of these cases. A short survey was sent to surgeons, including a multiple-choice questionnaire about their practice for atypical hyperplasia or lobular carcinoma in situ presenting in each trimester of pregnancy or at time of breastfeeding. Answer options included observation, immediate vacuum biopsy, immediate surgery, surgery in next trimester, surgery after delivery, and surgery after end of breastfeeding; based on the time of presentation. Out of the 671 practitioners invited, 97(14.5 %) responded to the survey. Participants were from 23 countries. Answers showed that management of gestational Atypical Ductal Hyperplasia (ADH) and Lobular Neoplasia (LN) was readily postponed by surgeons in favor of fetus safety while being cautious about risks of conservative management alone. Various methods of treatment are selected by surgeons for managing high-risk breast lesions during pregnancy. In the absence of relevant literature, decision making in a multidisciplinary team would be the best approach in these cases.

Adverse reaction regarding titanium-based marker clip: case report of a potential complication.

Adverse reaction to titanium-based breast marker clip is a very uncommon complication in medicine. We report a 65-year-old female patient who was referred with left breast lumpiness to the assessment clinic. Breast radiology with interesting sequelae following titanium clip insertion, in combination with literature review, will be discussed. The patient had a history of adverse skin reactions to base metals. However, no allergy specifically to titanium was reported. Imaging findings with regard to the symptomatic breast were nonspecific; thus, multiple core biopsies were taken, and titanium clip was inserted. Subsequent histological examination showed benign changes. However, 7 weeks later, the marked area became very tender and the same patient re-presented to the clinic, requesting removal of the metallic component. Following multidisciplinary meetings and discussions, the person underwent ultrasound-guided vacuum biopsy and the clip was removed. The symptoms completely resolved after the successful procedure, and histological examination revealed lymphocytic infiltration of the tissues. Reactions to titanium-based marker clips are rare and only limited records have been found in the literature. More cases need to be reported in order to establish the full significance of such adverse sequelae. It is recommended that medical history with regard to allergies, prior titanium clip insertions, should be discussed.

Abstract 3140: A prospective, double-blinded clinical study using atomic force microscopy for fast diagnosis and subtyping of low and high-risk breast cancers

Abstract Mechanical properties and physical interactions of cells and their microenvironment that occur at nanometre scale play a critical role in cancer progression and metastatic dissemination (https://physics.cancer.gov). Nanomechanical profiling of breast tissue enables fast and precise cancer diagnosis. Detecting extreme viscoelastic (soft) cancer cells in biopsies provides a direct biomarker of cancer aggressiveness (Plodinec et. al., 2012). In an ongoing single centre clinical trial conducted in a routine clinical setting we distinguish benign from cancerous breast lesions within 2.5 hours using an atomic force microscope (AFM)-based method known as ARTIDIS. ARTIDIS employs a micro-fabricated 20nm-sharp tip which indents 10,000 locations/sample to measure the stiffness of cellular and matrix structures. In a comprehensive web-based platform we collect, verify and analyze these 2.54 millions of AFM indentations in relation to over 100 clinical parameters /patient using artificial intelligence. In our interim analysis of core needle and vacuum biopsies (N=254), 34 samples were classified as B1 (normal); 127 as B2 (benign); 12 as B3 (uncertain malignant potential); 0 as B4 (suspicious); 18 as B5a (ductal carcinoma in situ), and 58 as B5b (malignant). The diagnostic AFM ROC curve of B1 and B2 lesions vs. all B5 lesions (CI 95%; 100% sensitivity, 90% specificity, AUC = 0.98) demonstrated ARTIDIS outstanding ability to detect cancer in samples with >80% neoplastic tissue. An analysis including lesions with <5% neoplastic tissue, (CI 95%; 96% sensitivity, 74% specificity, AUC = 0.91) showed similarly outstanding results. The secondary comparison of B3 vs. B2 lesions could inform clinical practice as these overlapped significantly (CI 95%; 50% sensitivity, 88% specificity, AUC = 0.712) suggesting low malignancy potential; comparing B3 to B5a (CI 95%; 89% sensitivity, 83% specificity, AUC = 0.842) might be clinically relevant as B3 lesions similar to B5a lesions could be considered higher risk. Comparing Luminal A to Luminal B samples (CI 95%; sensitivity 83%, specificity 70%, AUC = 0.77) suggested a potential of ARTIDIS to distinguish a more aggressive Luminal B subtype with positive nodal status in 12 out of 23 patients. The results demonstrate the ability of ARTIDIS to differentiate benign from malignant breast lesions within 2.5 hours in a routine clinical setting. The secondary endpoint results suggest that we are able to subclassify breast lesions into specific subtypes. In particular, luminal B cancers exhibit nanomechanical profiles that could be associated with better or worse prognosis as confirmed by the post-AFM positive nodal status. The final analysis (n=508) will determine clinical utility for primary endpoint and indications for future studies on nanomechanical characterization of breast cancer for prediction and treatment optimization. Citation Format: Rosemarie Burian, Ahmed Jizawi, Gabriel Zihlmann, Tobias Appenzeller, Philipp Oertle, Christian Raez, Roderick Y. Lim, Serafino Forte, Sophie Dellas, Simone Muenst, Tatjana Vlajnic, Ellen Obermann, Maria Ricci, Kevin Grimm, Ferdinand Niedermann, Marko Loparic, Marija Plodinec. A prospective, double-blinded clinical study using atomic force microscopy for fast diagnosis and subtyping of low and high-risk breast cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3140.

An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions. Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS. There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76). Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

Ultrasound-guided vacuum-assisted breast biopsy with a small-caliber device: A multicenter consecutive study of 162 biopsied lesions.

Objective:In this study, we aimed to analyze technical and diagnostic potential, and safety of the small-caliber vacuum-assisted biopsy (SCVAB) device in a multicenter consecutive study taking into consideration the type and location of breast lesion.Methods:We collected data from 5 breast imaging centers where radiologists used the SCVAB device for biopsies in 162 patients. We analyzed the conditions for using the SCVAB device according to the characteristics of the lesions, the volume of excision, and the analyzability obtained by biopsy samples.Results:The biopsies of 80 circumscribed masses, 61 complex lesions, and 24 microcalcification foci were included in the study. The reasons for choosing SCVAB as an initial technique were identified. A total of 47 lesions were removed with SCVAB; among them, 24 lesions were initially chosen for total excision. SCVAB was used as a second-choice biopsy method after core-needle biopsy failure in 20 cases. If SCVAB had not been available, vacuum-assisted biopsy would have been the most frequently used technique (106 under ultrasound, and 18 under stereotactical guidance).Conclusions:The SCVAB system is an alternative to classical vacuum biopsy, enabling representative samples to be obtained from lesions that are difficult to access, complex, small, or in cases of unsuccessful previous biopsy. The SCVAB system was determined as the chosen technique by the radiologists in this study due to feasibility, ergonomics and absence of side effects detected in this study.

Abstract 5013: Rapid generation of phenomic and functional profiles of patient-derived 3D cell culture models for identification of treatment vulnerabilities of breast cancer: Early results of the EFRE-PoP project

Abstract Targeted treatment for breast cancer subsets currently relies on the occurrence of estrogen, progesterone and Her2/neu receptors. For triple negative breast cancer (TNBC) there is no identified targeted therapy. The mutational landscape for breast cancer subsets has been characterized, but drug development has been limited due to the lack of appropriate preclinical models. Development of patient-derived xenograft models (PDX) has been difficult with take rates of below 30%.To establish a series of patient-derived 3D (PD3D) cell culture models as a versatile resource for ex vivo drug sensitivity screens as well as secondary establishment of PDX. We obtained breast cancer specimens either by biopsy or surgical resection. Upon arrival tumor tissue was minced and enzymatically digested. After subsequent filtering, respective tissue size fractions were seeded as Matrix-droplets into 24-well plates and incubated under standard conditions. Growth of PD3Ds was monitored daily by microscopy. PD3Ds were splitted when their diameter reached appropriate size. Organoids were than fixed and embedded. FFPE sections of donor-tissues and derived PD3D models were than used for IHC and inspected by a pathologist. In parallel, mutational profiling of snap-frozen tumor tissue and cell cultures was performed. All models were subjected to a semi-automated multi-drug response assay in a 384-well format to assess individual compound sensitivities.We established a scalable workflow for culturing and screening of PD3D cell cultures from limited quantities of breast cancer tissue from true-cut and vacuum biopsies as well as surgical specimen. Tissue fragments of ca. 3mm in diameter were sufficient to successfully establish PD3D cell cultures at a high yield. The time needed to expand PD3D cell cultures to obtain a sufficient amount of cells for subsequent molecular analyses varies from 2-6 weeks depending on amount and quality of samples as well as grade and stage of the donor tumor tissue. At the time, we can report a rate of culture establishment rate of 75% (11 models from 15 patient samples) for various clinical relevant subgroups, including TNBC, HR+, Her 2 pos. BC and one DCIS sample. The immunohistology and mutational profiles of these samples are currently being confirmed. The established workflow for culturing PD3D cell cultures offers high yield rates within a potentially clinically relevant time-frame for HTP cytotoxicity screenings. We are encouraged that this method is suitable for various molecular subtypes of breast cancer. Once adequately validated in co-clinical trials, PD3D models would make for an intriguing tool in supporting clinical decision-making for individual patients. Particularly patients with breast cancer refractory to standard of care compounds could benefit from this approach. Citation Format: Verena I. Kiver, Guido Gambara, Olga Gorea, Jens-Uwe Blohmer, Philipp Jurmeister, Carsten Denkert, Alessandra Silvestri, Caroline M. Schweiger, Maxine Silvestrov, Ulrich Keilholz, Christian R. Regenbrecht. Rapid generation of phenomic and functional profiles of patient-derived 3D cell culture models for identification of treatment vulnerabilities of breast cancer: Early results of the EFRE-PoP project [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5013.

Relevance of B3 lesions in breast diagnosis – frequency and therapeutic consequences

AbstractWith improvements in breast imaging and minimally invasive interventions, detection of early breast cancer has increased. However, with the improved diagnostic capabilities, the risk of false-positive benign lesions as well as lesions classified as B3 by histopathology has also increased. Varying rates of malignancies are associated with B3 lesions, raising the question of whether such lesions should always be surgically removed. The results of our retrospective analysis should assist in this decision-making process.307 core needle or vacuum-assisted needle biopsies in which B3 lesions were found were examined. The most common lesions were intraductal papillomas (44 %), atypical ductal hyperplasia (22.8 %), flat epithelial atypia (9.4 %), phyllodes tumours (6.5 %), radial scars (5.9 %), LIN 1 (4.9 %), complex fibroadenomas (3.3 %) and LIN 2 (1.6 %). The frequencies depended considerably on whether the tissue was obtained by core biopsy or vacuum biopsy. Stereotactic vacuum biopsy was generally performed in the case of microcalcification not apparent on sonography. Lesions visible on ultrasound had core needle biopsy.Surgery was performed in 254 cases and a malignancy was found in 27.2 % on the final histopathology. Malignancy was found in 24.6 % of 114 cases initially diagnosed as intraductal papilloma. Similarly, cancer was discovered in 48.4 % of the 62 cases of atypical ductal hyperplasia, in 2.4 % of the 41 cases of flat epithelial atypia, complex fibroadenoma and phyllodes tumour, in 20.7 % of the 29 cases of LIN 1 and radial scar as well as in 50 % of the 8 cases of LIN 2, adenomyoepithelioma and atypical apocrine metaplasia.These data indicate the necessity for complete surgical removal of a B3 lesion when it is discovered using the core needle or vacuum-assisted biopsy technique. The decision not to perform surgery can be made when the risk of associated malignancy is deemed low in the clinical pathology conference, but careful follow-up is essential.

Abstract P4-02-12: Predicting surgical upgrade of breast lesions detected by MRI-guided biopsy

Abstract Background: Patients who have suspicious breast lesions identified with MRI without mammographic- or ultrasound-correlated biopsy require MRI-guided biopsy. However, MRI-guided biopsy may underestimate the pathology due to intrinsic heterogeneity, in which subsequent surgical excision may reveal an upgrade. The reported upgrade rate is variable across studies, subclasses of lesion, and needle gauge, and no associative factors have been identified. This study investigated demographic and histologic characteristics of lesions that underwent MRI-guided biopsy to determine possible factors for predicting later upgrade at surgery. Methods: All MRI-guided vacuum biopsies performed between 2012 and 2017 at GWU Breast Imaging Center were reviewed. Surgical excision was performed for high risk lesions and imaging discordance in benign lesions. Variables investigated include patient age, menopausal status, personal/family history of breast cancer and breast pathology. T-test and Pearson's chi-squared test were used to determine statistical significance (alpha=0.05). Results: Of 379 lesions from 295 patients that underwent MRI-guided biopsy, 117 lesions from 96 patients underwent subsequent surgical excision. Pathology of the 117 lesions included benign (14/117; 12%), ALH (17/117; 15%), LCIS (10/117; 9%), ADH (10/117; 9%), papilloma (25/117; 21%), radial scar (12/117; 10%), DCIS (13/117; 11%), invasive cancer (10/117; 9%), and others (6/117; 5%). 14 of 117 lesions (12%) were upgraded at surgery: 5 upgraded from benign to high-risk, 1 upgraded from benign to DCIS, 4 upgraded from high risk to DCIS, 1 upgraded from high risk to invasive cancer and 3 upgraded from DCIS to invasive cancer. All 14 patient with upgrades (100%) had a personal history of breast cancer. No association was found with age, menopausal status, breast pathology, or family history. Conclusions: Our study demonstrated a surgical upgrade rate of 12%. All upgrades occurred in women with a personal history. We suggest that patients with a personal history of breast cancer pose a higher risk of surgical upgrade at excision. Citation Format: Chen A, Brem R. Predicting surgical upgrade of breast lesions detected by MRI-guided biopsy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-02-12.

Not all false positive diagnoses are equal: On the prognostic implications of false-positive diagnoses made in breast MRI versus in mammography / digital tomosynthesis screening

BackgroundBreast magnetic resonance imaging (MRI) has been reported to frequently result in false-positive diagnoses, limiting its positive predictive value (PPV). However, for PPV calculation, all nonmalignant tissue changes are equally considered false-positive, although the respective prognostic importance, and thus patient management implications, of different pathologies may well differ. We investigated the pathology of false-positive diagnoses made by MRI compared with radiographic (digital mammography/tomosynthesis [DM/DBT]) screening.MethodsWe conducted an institutional review board-approved prospective analysis of 710 consecutive asymptomatic women at average risk for breast cancer who underwent vacuum biopsy with or without surgical biopsy for screen-detected DM/DBT (n = 344) or MRI (n = 366) findings. We compared the frequency of false-positive biopsies (given by PPV3), as well as the types of nonmalignant tissue changes that caused the respective false-positive biopsies. In an order of increasing relative risk of subsequent breast cancer, pathologies of false-positive biopsies were categorized as nonproliferative, simple proliferative, complex proliferative, or atypical proliferative (including lobular carcinoma in situ/lobular intraepithelial neoplasia). The Mann-Whitney U test was used to compare distributions.ResultsHistology yielded nonmalignant tissue in 202 of 366 biopsies done for positive MRI studies and 195 of 344 biopsies for positive DM/DBT studies, respectively, yielding a similar PPV3 percentages of 44.8% (164 of 202) and 43.3% (149 of 202) for both methods. However, the distribution of tissue types that caused false-positive diagnoses differed significantly (p < 0.0001). On the basis of MRI, high-risk atypical proliferative changes (40.1%; 81 of 202) were most common, followed by complex proliferative changes (23.8%; 48 of 202). In DM/DBT, low-risk, nonproliferative changes were the dominant reason for false-positive diagnoses (49.7%; 97 of 195), followed by simple proliferative changes (25.2%; 51 of 195). Low-risk nonproliferative changes resulted in false-positive diagnoses based on MRI as infrequently as did high-risk atypical proliferative changes based on DM/DBT (18.8% [38 of 202] vs. 18.0% [35 of 195]). The likelihood of a false-positive diagnosis including atypias was twice as high in women undergoing biopsy for MRI findings (81 of 202; 40%) as for those with DM/DBT findings (35 of 195; 18%).ConclusionsThe prognostic importance, and thus the clinical implications, of false-positive diagnoses made on the basis of breast MRI vs. radiographic screening differed significantly, with a reversed prevalence of high- and low-risk lesions. This should be taken into account when discussing the rate of false-positive diagnoses (i.e., PPV levels of MRI vs. radiographic screening). Current benchmarks that rate the utility of breast cancer screening programs (i.e., cancer detection rates and PPVs) do not reflect these substantial biological differences and the different prognostic implications.

Ultrasound Guided Therapeutic Excisional Vacuum Assisted Biopsy in Breast Fibroadenomas.

The aim of this study was to evaluate the performance of ultrasound (US) guided Vacuum Assisted Biopsy (VAB) in the therapeutic excision of breast fibroadenomas. Patients who underwent excisional US guided VAB of their fibroadenomas between December 1999-May 2001 were retrospectively evaluated. Seventy-eight patients with BI-RADS category 3 and 4a lesions (one lesion per patient) with a maximum diameter smaller than 3 cm were enrolled in the study. Fifty-one of those were diagnosed with fibroadenoma. Biopsies were performed with a 11G needle using the Mammotome (Johnson & Johnson, New Jersey, USA) vacuum biopsy device. Patients were followed up with US for three years. Follow-ups were done semiannually in the first year and annually afterwards. Ten patients (19%) were found to have residual lesions in the first week after the biopsy. Additional eight patients (15%) were found to have residual-recurrent lesions in their annual follow up. However, none of these eight lesions demonstrated growth during the three year follow-up. The initial size of the FA was not found to be significantly different between the lesions which were completely excised with no residue or recurrence and those which were not (p>0.05). The VAB method for the therapeutic excision of small FAs or other benign lesions is practical and easily tolerated by patients. Lesions smaller than 3 cm should be preferred for VAB. A multidisciplinary clinical environment is necessary for each step of the treatment.

MRI-guided breast vacuum biopsy: Localization of the lesion without contrast-agent application using diffusion-weighted imaging

ObjectiveIn magnetic resonance-guided breast vacuum biopsies, the contrast agent for targeting suspicious lesions can typically be applied only once during an intervention, due to the slow elimination of the gadolinium chelate from the extracellular fluid space. This study evaluated the feasibility of diffusion-weighted imaging (DWI) for lesion targeting in vacuum assisted magnetic resonance imaging (MRI) biopsies. ConclusionDWI may be used as an alternative to dynamic contrast-enhanced MRI with the advantage of reproducibility. However, the targeted lesion requires the characteristics of a mass-like lesion, substantial diffusion restriction, and a minimum size of approximately 1cm.

A matrix of morphology and distribution of calcifications in the breast: Analysis of 849 vacuum-assisted biopsies

ObjectiveThe purpose of this retrospective analysis was to evaluate the likelihood of malignancy in prospectively categorized BI-RADS 4 and BI-RADS 5 calcifications. Material and methodsThis analysis included 849 women who underwent vacuum biopsy for BI-RADS 4 (with the subgroups 4A, 4B and 4C) or BI-RADS 5 calcifications between February 2007 and May 2015. Calcifications were classified according to the morphology and distribution descriptors of the BI-RADS lexicon (BI-RADS 4th edition lexicon). A standardized scheme (matrix) was used to combine the characteristics of the grouped calcifications with the BI-RADS assessment category. ResultsOverall, 275/849 (32%) lesions were found to be malignant. 285/327/208/29 calcified lesions were prospectively classified as BI-RADS 4A/4B/4C/5 indicating a risk for malignancy of 16%/27%/55%/90%, respectively. The morphology descriptors predicted the risk for malignancy as follows: typically benign (n=55): 2%; indeterminate (n=676): 27%; typically malignant (n=118): 80%. The distribution descriptors correlated with a malignant histology as follows: diffuse (n=0); round or oval (n=261): 22%; regional (n=398): 33%; segmental (n=106): 42%; linear or branching (n=85): 55%. There was a significant difference between the descriptor categories (p<0.0001). ConclusionA standard scheme combining the morphology and distribution characteristics proved to be a helpful tool in diagnosis of calcifications, bridging the gap between description and classification of these lesions.

Magnetic Resonance Imaging Guided Vacuum Assisted and Core Needle Biopsies.

The purpose of this study to present the results of Magnetic resonance imaging (MRI) guided cutting needle biopsy procedures of suspicious breast lesions that can be solely detected on Magnetic resonance (MR) examination. The study included 48 patients with 48 lesions which were solely be observed in breast MRI, indistinguishable in ultrasonography and mammography, for MR guided vacuum-assisted cutting needle biopsy and 42 patients with 42 lesions for MR guided cutting needle biopsy for the lesions of the same nature. MR imaging was performed using a 1.5-Tesla MRI device. Acquired MR images were determined and biopsy protocol was performed using computer-aided diagnosis system on the workstation. Vacuum biopsies were performed using 10 G or 12 G automatic biopsy systems, cutting needle biopsy procedures were performed using fully automated 12 G biopsy needle. All biopsy procedures were finalized successfully without major complications. The lesions were 54 mass (60%), 28 were non-mass contrast enhancement (31%) and 8 were foci (9%) in the MR examination. Histopathological evaluation revealed 18 malignant (invasive, in-situ ductal carcinoma and lobular carcinoma), 66 benign (apocrine metaplasia, fibrosis, fibroadenomatoid lesion, sclerosing adenosis, fibrocystic disease and mild-to-severe epithelial proliferation) and 6 high-risk (atypical ductal hyperplasia, intraductal papilloma, radial scar) lesions. Magnetic resonance guided vacuum and cutting needle biopsy methods are successful methods fort he evaluation of solely MRI detected suspicious breast lesions. There are several advantages relative to each other in both methods.

Lesions with unclear malignant potential (B3) after minimally invasive breast biopsy: evaluation of vacuum biopsies performed in Switzerland and recommended further management.

BackgroundHistopathological B3 lesions after minimal invasive breast biopsy (VABB) are a particular challenge for the clinician, as there are currently no binding recommendations regarding the subsequent procedure.PurposeTo analyze all B3 lesions, diagnosed at VABB and captured in the national central Swiss MIBB database and to provide a data basis for further management in this subgroup of patients.Material and MethodsAll 9,153 stereotactically, sonographically, or magnetic resonance imaging (MRI)-guided vacuum-assisted breast biopsies, performed in Switzerland between 2009 and 2011, captured in a central database, were evaluated. The rate of B3 lesions and the definitive pathological findings in patients who underwent surgical resection were analyzed.ResultsThe B3 rate was 17.0% (1532 of 9000 biopsies with B classification). Among the 521 lesions with a definitive postoperative diagnosis, the malignancy rate (invasive carcinoma or DCIS) was 21.5%. In patients with atypical ductal hyperplasia, papillary lesions, flat epithelial atypia, lobular neoplasia, and radial scar diagnosed by VABB, the malignancy rates were 25.9%, 3.1%, 18.3%, 26.4%, and 11.1%, respectively.ConclusionB3 lesions, comprising 17%, of all analyzed biopsies, were common and the proportion of malignancies in those lesions undergoing subsequent surgical excision was high (21.5%).