RPS 1302 - Imaging-guided breast biopsy innovations

Purpose:

To investigate the role of shear-wave elastography-guided (SWE) core-needle biopsy for the accurate determination of breast cancer immunohistochemical subtypes.

Methods and materials:

This study was conducted between May 2018 and April 2019 and included adult patients who had a lesion larger than 1 cm and were referred for a core-needle biopsy. Patients were divided into two groups by block randomisation. B-Mode ultrasonography-guided biopsy (control group, group 1) and SWE-guided biopsy (group 2) were performed in a total of 60 lesions. The biopsy in the control group was recorded as biopsy A, the SWE-guided biopsy from the relatively rigid area of ​​the lesion was recorded as biopsy B, and the biopsy from the relatively less rigid area of ​​the lesion was recorded as biopsy C. Diagnosis and immunohistochemical results were recorded and compared with the surgical results.

Results:

The mean lesion sizes were 33.2 ± 22.6 mm in group 1 and 27.8 ± 11.9 mm in group 2. Sensitivity was 96.7% in biopsy A and 100% in biopsy B and C. Benign-malignant accuracy was 94.7%, 100%, and 90%, and diagnostic accuracy was 89.5%, 100%, and 90% in biopsy A, B, and C, respectively. When immunohistochemical markers were evaluated in one patient (14.3%) at biopsy A, Her2 receptor status was wrong. When the 10% difference in ER, PR, and Ki67 rates were considered significant, the accuracy of ER was highest in biopsy B as 77.8% (p = 0.04). Accuracy in immunohistochemical subtyping was 100% in biopsy B, and 71.4% in biopsy A and C (p = 0.08).

Conclusion:

SWE-guided core-needle biopsy of breast lesions increased sensitivity, diagnostic accuracy, and accuracy in immunohistochemical subtyping to 100%.

Limitations:

See attached file.

Ethics committee approval

Approved by the institutional ethics committee.

Funding:

Funded by the University Department of Scientific Research Projects.

Purpose:

Breast cancer patients with lymph node metastases at diagnosis often undergo neoadjuvant therapy. Identification of a LN which regressed after NAC remains a challenge. A new concept of targeted axillary lymph node dissection has recently been proposed which involves the removal of a node with documented metastases in addition to the removal of the nodes most likely to harbour disease.

The aim of the study was to evaluate the possibility of tattooing biopsied nodes prior to NAT and identifying them at the time of surgery.

Methods and materials:

Carbon suspension was injected into axillary LNs before starting NAC. During surgery, an attempt was made to identify the tattooed LN, which was removed and sent for pathological evaluation. All patients underwent a sentinel lymph node biopsy and/or axillary lymph node dissection as mandated by their clinical status.

Results:

63 patients underwent tattooing of involved axillary lymph nodes. At surgery, a tattooed node was identified in 60 patients (95.2%). Of 50 patients in whom both radioactivity and tattoo were identified in axillary LNs, 40 (80%) lymph nodes were radioactive and tattooed, however in 10 patients (20%) the tattooed LN was not radioactive.

Conclusion:

Ultrasound-guided tattooing of involved axillary lymph nodes prior to neoadjuvant therapy is a safe, effective, and easily performed method of marking these nodes for future identification at the time of surgery. We found the tattooing was helpful in identifying the marked LN in the majority of cases. In our study, the identification rates of tatooed nodes was about 95.2%.

Limitations:

The main limitation was the small number of patients.

Ethics committee approval

The study protocol was approved by our institutional review board and patients signed informed consent prior to injection.

Funding:

No funding was received for this work.

Purpose:

To determine the minimum number of stereotactic 9-gauge vacuum-assisted breast biopsy (VABB) specimens required to establish a final histopathological biopsy diagnosis of mammographically suspicious lesions.

Methods and materials:

A total of 120 women referred for VABB of 129 mammographically suspicious lesions were included (December 2017-October 2018). Stereotactic 9-gauge VABB was performed, acquiring twelve specimens per lesion. Calcification retrieval was assessed with individual specimen radiography. Each specimen was histologically analysed in chronological order and findings were compared with the final histopathological result after assessment of all 12 specimens and with results of surgical excision. Cumulative diagnostic yield per specimen was calculated.

Results:

In total, 131 VABB procedures were performed in 120 women (mean age 59y). In 95% (95%CI 90%-98%) of the procedures, a final histopathological biopsy diagnosis was reached after 6 specimens. After 9 specimens, the final diagnosis was established in all 131 cases. In the 41 patients with a DCIS or invasive diagnosis at biopsy, there were 8 procedures (20%) where calcifications were retrieved before the diagnostic specimen was obtained. Underestimation of subsequent resection diagnosis occurred in 6 out of 30 excised lesions classified as DCIS(20%) and in 1 out of 4 excised high-risk lesions.

Conclusion:

With 6 stereotactic 9-gauge VABB specimens, a final histopathological biopsy diagnosis could be established in 95% (95%CI 90%-98%) of the procedures. Taking 9 specimens seems to be optimal. Ending the stereotactic VABB procedure as soon as calcifications are retrieved may cause false-negative results.

Limitations:

Study-pathologist was not blinded to study design and clinical histopathological result. Fixed biopsy protocol was used, irrespective of lesion size and location relative to the needle.

Ethics committee approval

Approval from the IRB of the UMCU and written informed consent from study participants was obtained.

Funding:

Funding was received from Hologic.

Purpose:

To determine the failure rate of stereotactic core-needle biopsy (SCNB) and its causes and final outcome in women recalled for microcalcifications at screening mammography.

Methods and materials:

We included a series of 466,647 screens obtained in a Dutch screening region between January 2009 and January 2017. Radiology reports and pathology results were obtained of all recalls during two-year follow-up.

Results:

A total of 2,815 women (19.9% of 14,142 recalls) were recalled for suspicious microcalcifications. SCNB was indicated in 2,220 women, of which 10 refused a biopsy. Breast cancer (DCIS or invasive cancer) was diagnosed in 671 of 2,210 women (30.4%). SCNB was technically not feasible in 36 women (1.6%, 36/2,210), of which ten underwent surgical biopsy (5/10 positive). Pathology showed no calcifications and no malignancy in the SCNB specimen in 30 women after SCNB (1.5%, 30/1,974), of which 5 proved to have breast cancer at subsequent surgery. The remaining 25 women, without a diagnosis of breast cancer two years after the recall, underwent follow-up imaging (n=14), surgical excision with the benign outcome (n=4), or were asked to re-attend the screening programme without follow-up (n=7). Breast cancer was diagnosed in 15% of women (10/66) who experienced either SCNB cancellation due to technical limitations, or whose SCNB yielded no malignancy in the absence of calcifications in the specimen.

Conclusion:

Although the failure rate of SCNB is very low, a close surveillance with a low threshold for surgical biopsy is warranted as we found that breast cancer was present in 15% of these women.

Limitations:

Due to differences in programmes, our data may not be extrapolated to other screening programmes.

Ethics committee approval

Ethical approval was waived.

Funding:

No funding was received for this work.

Purpose:

To identify clinical and imaging features of upgrade for invasive disease in patients with conventional imaging occult ductal carcinoma in situ (DCIS) diagnosed on MRI-guided biopsy.

Methods and materials:

Results of consecutive patients with MRI-detected pure DCIS, occult on conventional imaging (CI) including mammography and ultrasound performed in a tertiary academic hospital in 2009-2018, were reviewed. Women were divided into 2 groups based on the gold standard final pathology: Pure DCIS or DCIS with an invasive component. Final surgical pathology was used to validate MRI results.

Results:

50 patients fulfilled the inclusion criteria and formed the study cohort. 46 patients (92%) had non-mass enhancement (NME) yielding pure DCIS diagnosis compared to 4 enhancing masses. The most common NME distribution was focal (22, 48%). The most common kinetic pattern was persistent (24, 48%). Overall, 12 patients (24%) were upgraded to invasive malignancy on final pathology. The only parameter showing statistically significant association with upgrade was kinetic characteristics; 10 (40%) of the women with plateau or washout kinetics, versus 2 (8%) of the women with progressive kinetics were upgraded to invasive cancer on surgery (P=0.034). On multivariate analysis, progressive kinetics remained inversely associated with upgrade when compared to washout kinetics (OR=0.012; P<0.021; 95% CI 0.02;0.73).

Conclusion:

The washout kinetic pattern of enhancement proves to be the best predictor of invasion in conventional imaging occult DCIS diagnosed on MRI-guided biopsy. It may have implications for treatment planning as sentinel lymph node biopsy may be considered in the primary surgical procedure for this subset of patients. Larger studies should be encouraged to consolidate our findings.

Limitations:

Retrospective design. High level of interobserver variability in DCIS. No diffusion calculations.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate technical and pathologic outcomes of tomosynthesis-guided vacuum-assisted biopsy (DBT-VAB) performed on low-contrast, non-calcific lesions (LC-NCL) found at mammography.

Methods and materials:

Of women referred to DBT-VAB in our institution between January 2017 and March 2018, we retrospectively included 152 patients with 154 sonographically occult LC-NCL. Two radiologists with 15 and 2 years of experience in breast imaging worked in consensus to review mammographic examinations, radiology reports, and pathology reports to record patients’ and lesions’ features, the rate and reasons for technical failure, as well as pathologic and follow-up results (up to 12 months).

Results:

DBT-VAB was unfeasible in 14/154 LC-NCL (9%) presenting as architectural distortions (11/14), asymmetry (2/14), and opacity (1/14). Reasons were lack of target visualisation and deep location in 13/14 and 1/14 cases, respectively. None of the patients developed malignancy at imaging follow-up. DBT-VAB was performed in the remaining 140/154 (91%) LC-NCL, including 66/140 (47%) architectural distortions, 46/140 (33%) opacities, 19/140 (14%) asymmetries, and 9/140 (6%) mixed lesions. Complications occurred in 11/138 (8%) patients, including 9 haematomas, 1 vasovagal reaction, and 1 subcutaneous emphysema. Biopsy found 25/140 (18%) malignant lesions (B5), 36/140 (26%) high-risk lesions (B3), 76/140 (54%) benign lesions (B2), and (2%) normal tissue in 3/140 cases (B1). After surgical excision, 7/36 high-risk lesions were upgraded to malignancy (2 invasive and 5 DCIS), corresponding to an underestimation rate of 19%. Additionally, surgical excision and/or follow-up demonstrated malignancy in 2/9 cases of imaging-pathology discordant B2 lesions. No malignancy was found at surgical excision of B1 lesions. Overall, the malignancy rate was 24%.

Conclusion:

DBT-VAB was feasible in the majority of LC-NCL, with a few complications. About one-fourth of LC-NCL was malignant, supporting the need for biopsying those mammography findings.

Limitations:

Monocentric and retrospective design.

Ethics committee approval

Informed consent waived because of the retrospective design.

Funding:

No funding was received for this work.

Purpose:

To analyse the management and outcome of calcified lesions with a low risk of malignancy on mammography (BI-RADS category 4a) and uncertain malignant potential (B3) detected at stereotactic vacuum-assisted breast biopsy (SVAB).

Methods and materials:

Retrospective analysis of 91 consecutive SVAB procedures was performed. Inclusion criteria were BI-RADS category 4a calcified lesions on screening mammography and histologic diagnosis of B3 lesions. The three groups of patients were defined, based on the post-biopsy multidisciplinary team decisions, as 1) with a definite histology after surgical excision, 2) with breast dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) after SVAB, prior to surgical excision, and 3) the group that is followed by annual physical assessment and mammography. Malignancy rates were evaluated for each group.

Results:

The first group consisted of 13 patients (14.3%), the second of 20 (22.0%), and the third of 58 (63.7%). Atypical ductal hyperplasia lesions (isolated or associated with other B3 lesions) were found in 45.0% patients, papillary lesions in 31.9%, lobular intraepithelial neoplasia in 15.4%, flat epithelial atypia in 6.6%, and radial scar in 1.1%, with no significant difference of B3 lesions histologic types between the three groups (p=0.09). An upgrade to malignancy in the first group was 38.5% (5 patients) and in the second, 20.0% (4 patients). Taking into account the absence or presence of angiogenesis on DCE-MRI, a negative predictive value of DCE-MRI was 92%. In the third group, 1-year to 6-year follow-up was negative for breast malignancy.

Conclusion:

The rates of upgrade to malignancy in our study were high, up to 38.5%. The post-biopsy DCE-MRI may be an useful tool for further management of B3 lesions.

Limitations:

Retrospective analysis study.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To compare the calcification retrieval performance of upright tomosynthesis-guided vacuum-assisted breast biopsy (Tomo VAB) with that of prone stereotactic vacuum-assisted breast biopsy (ST VAB).

Methods and materials:

A retrospective review of records revealed 176 calcification lesions not detected by ultrasound in 176 women who underwent Tomo VAB or ST VAB. A mean of 6 specimens per lesion were obtained using 9-gauge or 11-gauge needle. Calcification retrieval success was defined as identification of calcifications on specimen radiographs. Procedure time, estimated exposure dose, and complications were also evaluated.

Results:

During the study period, 88 ST VAB in 88 patients and 88 Tomo VAB in 88 patients were performed. Each calcification retrieval success rate was the same (99% vs 99%). No complications were observed in either group. Mean procedure time was shorter with Tomo VAB vs ST VAB (16 vs 26 min, respectively; p<.001), and fewer estimated exposure doses were acquired with Tomo VAB vs ST VAB (4.35mGy vs 9.6mGy, respectively; p<.001) as during Tomo VAB, only 3 reference tomosynthesis images were generally obtained, while 8 reference 2D images were generally obtained during ST VAB.

Conclusion:

Tomo VAB has the same degree of clinical performance for diagnosing calcifications as ST VAB and can be performed in less than two thirds of the ST VAB procedure time and with about half of the exposures in ST VAB.

Limitations:

This study had some limitations, mainly resulting from its retrospective single-institution nature and small patient numbers. Another limitation is that our comparison groups were not randomised but were rather divided by time.

Ethics committee approval

This retrospective study was approved by our institutional review board and the requirement to obtain informed consent was waived.

Funding:

No funding was received for this work.

Purpose:

To investigate the usage of VAE techniques as an alternative approach to open excision diagnostic procedure for B3 lesions in clinical practice.

Methods and materials:

Retrospective data collection was via K62, National Health Service Breast Screening Programme (NHSBSP) database, to identify all patients diagnosed with B3 lesions on biopsy between April 2015-March 2019. Audit standard was NHSBSP No.49 guidelines on B3 lesions. Mammographic findings, biopsy type, management, and final pathology results were recorded for each patient. Upgrade/downgrade rates were calculated for each subtype and compared with the previous years.

Results:

105 patients had B3 histopathology on core biopsy (CB), 14 G or vacuum-assisted biopsy (VAB) 9G. From these, 72 patients had VAE, either stereotactic or under ultrasound, and 20 surgical excision as second line, decided by MDT. 70 of the B3 lesions stayed the same/were downgraded to B2 in their final histopathology. 2 of the B3 lesions were upgraded to B5a (high grade DCIS) by VAE as second line. There was a progressive increase in second-line VAE from 58% in 2015 and to 80% in 2019. The unit was 94% concordant with the standard in terms of performed investigation for each lesion subtype.

Conclusion:

The data shows our VAE policy saves patients having unnecessary operations for benign disease.Therefore, VAE should always be considered as an alternative pathway to the open surgical excision for the majority of B3 lesions in concordance with the official guidelines. This would potentially reduce the benign open biopsy rate whilst maintaining accuracy of cancer diagnosis. Management of all B3 lesions should be discussed in the MDT meetings.

Limitations:

Single-centre study with a limited number of patients and data.

Ethics committee approval

n/a

Funding:

No funding was received for this work.