RPS 1302 - Imaging-guided breast biopsy innovations

RPS 1302-1
Shear-wave elastography-guided core-needle biopsy for the determination of breast cancer molecular subtypes
Purpose: To investigate the role of shear-wave elastography-guided (SWE) core-needle biopsy for the accurate determination of breast cancer immunohistochemical subtypes.
Methods: 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
RPS 1302-2
Ultrasound-guided tattooing of axillary lymph nodes in patients prior to neoadjuvant therapy and the identification of tattooed nodes at the time of surgery
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.

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: 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.

RPS 1302-3
Stereotactic 9-gauge vacuum-assisted breast biopsy: how many specimens do we need?
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: 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: Approval from the IRB of the UMCU and written informed consent from study participants was obtained.
Funding: Funding was received from Hologic.
RPS 1302-4
Failure of stereotactic core-needle biopsy in women recalled for suspicious microcalcifications at screening mammography: frequency, causes, and final outcome in an observational follow-up study
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: 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: Ethical approval was waived.
Funding: No funding was received for this work.
RPS 1302-5
Conventional imaging occult DCIS diagnosed on MRI-guided biopsy: can we predict upgrade on surgical pathology?
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: 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: n/a
Funding: No funding was received for this work.
RPS 1302-6
Tomosynthesis-guided vacuum-assisted biopsy for mammographic low-contrast, non-calcific lesions: technical and pathologic results
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: 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: Informed consent waived because of the retrospective design.
Funding: No funding was received for this work.
RPS 1302-7
Value of targeted fusion US with virtual mammographic navigation in B3 lesions
Purpose: To evaluate the role of second-look targeted fusion MMG/US navigation in BI-RADS 3 lesions in comparance to standard HHUS.
Methods: 45 women with 50 B3 lesions on mammography followed by ultrasound were studied by two experts for breast US (GV18y.exp; PI25 y.exp) blinded to each other results. The first radiologist performed standard HHUS and the second fusion ultrasound with virtual mammographic navigation. Fusion US and conventional HHUS were performed on My LAB Twice (ESAOTE) with a linear transducer BL433 (3-18MHz). 25 B3 lesions were biopsied under US and 10 with stereotactic MMG, 15 follow up for 2 years. The ROC-curves were compared for both methods.
Results: B3 lesions were upgraded to B5 by HHUS in 14 pts, and in 20 by fusion US, with cancer proven in 18 pts. B3 lesions were downgraded to B2 in 20 by HHUS, and in 25 by fusion US, none of them appearing to have cancer. ROC-curve analysis showed that fusion was superior to HHUS with AUC 0,889 (95%CI 0,768 to 0,960), and 0,794 (95%CI 0,656 to 0,895), respectively. Fusion US were superior to HHUS in the cases of grouped microcalcifications and subtle less than 4 mm B3 lesions. Agreement in BIRADS category between the examiners was 0,82.
Conclusion: Fusion US with virtual mammographic navigation may help in identify microcalcification and subtle less than 4 mm B3 lesions, thus increasing the diagnostic performance of targeted US.
Limitations: Limitations of the study were consecuted patients with B3 lesions and a small group of cancer patients.
Ethics: Written consent was received from all patients. The examination was approved by the Institutional Ethical Committee.
Funding: No funding was received for this work.
RPS 1302-8
Calcified lesions with a low risk of malignancy on mammography and uncertain malignant potential (B3) detected at stereotactic vacuum-assisted breast biopsy
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: 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: n/a
Funding: No funding was received for this work.
RPS 1302-9
Comparison of calcification retrieval performance between upright tomosynthesis-guided and prone stereotactic vacuum-assisted breast biopsy
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: 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: 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.
RPS 1302-10
The value of contrast-enhanced ultrasound in breast cancer biopsy (recorded)
Purpose: To investigate the value of contrast-enhanced ultrasound (CEUS) in breast cancer biopsy.
Methods: A total of 49 consecutive patients with biopsy-confirmed breast cancer were enrolled in this retrospective cohort study. All patients underwent CEUS to evaluate the homogeneity of perfusion of breast lesions. For lesions showed homogeneous enhancement on CEUS, the centre part and peripheral part were biopsied respectively. For heterogeneously enhanced lesions, the biopsies were thus performed targeting both the enhanced regions and non-enhanced regions. The sample adequacy rate and core cancer involvement of the biopsy cores taken from the enhanced regions were compared with those from the non-enhanced regions.
Results: A total of 53 breast cancer lesions were biopsy-confirmed in 49 patients. CEUS revealed homogeneous enhancement in 8 of 53 breast cancers (15.1%) and heterogeneous enhancement in 45 of 53 breast cancers (84.9%). The sampling adequacy rate was 98.5% for biopsy cores taken from the enhanced regions, significantly higher than those from the non-enhanced regions (72.9%, P<0.01). The core cancer involvement was higher in enhanced regions than non-enhanced regions (median: 55% vs 30%, P<0.01).
Conclusion: CEUS can differentiate the active area and necrotic fibrosis area of breast tumours by displaying the microvessels and might be the possible solution to the problem of biopsy site selection.
Limitations: This study might be limited by its retrospective study design and that all the patients were enrolled with biopsy-proven breast cancer.
Ethics: This retrospectively designed, single-institution study was approved by the local institutional review board (XHEC-D-2019-015).
Funding: No funding was received for this work.
RPS 1302-11
Vacuum-assisted excision (VAE) as an alternative to open surgical excision for B3 lesions in a screening clinical unit
Purpose: To investigate the usage of VAE techniques as an alternative approach to open excision diagnostic procedure for B3 lesions in clinical practice.
Methods: 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: n/a
Funding: No funding was received for this work.
RPS 1302-12
Ultrasound-guided core-needle biopsy of the axillary lymph nodes in different subtypes of newly diagnosed breast carcinoma
Purpose: To assess the diagnostic accuracy of US-guided core needle biopsy (CNB) in the detection of axillary LN metastasis in different subtypes of breast cancer.
Methods: From May 2018 through May 2019, in a prospective study of 1153, 153 cases with biopsy-proven breast cancer showed suspicious axillary LNs in ultrasound. They underwent axillary sampling and then pathologic correlation. 65 patients met the inclusion criteria.
Results: Axillary US-guided CNB correctly identified 55 (84.5%) of the 65 involved LNs. The sensitivity, specificity, positive/negative predictive values, and positive/negative likely hood ratio (LR) of CNB were 75.5 %, 93.7%, 92.5%, 78.9%, 12.2, and 0.25 respectively (p value< 0.001).
Interestingly, we found that in hormone-positive tumours, the sensitivity and PPV of axillary CNB were higher, 80.9% and 94.4% respectively (p<0.001).
In Her-2 negative cancers, the sensitivity of CNB was more, with no statistically significant difference.
Conclusion: CNB is a fast, simple and minimally invasive technique with a high LR (+) in ruling in and good LR (-) in ruling out the axillary metastasis. Because of the reliability of CNB in preoperative diagnosis of LN metastasis, we could suggest avoiding sentinel LN surgery in post-CNB negative cases similar to post-CNB positive cases. Biological markers seem to affect the CNB pathologic results; this emphasis should be investigated in the studies with larger sample size.
Limitations: The limitations of CNB are including mistargeting of the LN, the discordance of postoperative pathology and biopsy in micrometastasis, the failure of biopsy of deeply located/small-sized LN, trauma to the adjuscent tissue, and pain.
Ethics: This study achieved ethical approval from the Institutional Board of Motamed cancer institute (ACECR) with approval number of 9610101.
Funding: No funding was received for this research.
RPS 1302-13
Breast biopsy performed the same day as diagnostic imaging: does it impact patient care?
Purpose: To determine the time to surgery for patients undergoing diagnostic breast imaging and breast biopsy on the same day compared to patients with imaging and biopsy on separate days.
Methods: Retrospective case-control study reviewing 300 patients from 1/1/2009 to 1/1/2017 was performed. Review included 150 patients with diagnostic breast imaging and breast biopsy performed the same day compared to 150 patients with biopsy performed on days following imaging. Time interval from diagnostic imaging to biopsy, pathological diagnosis, surgical consultation, and surgery was determined.
Results: Same-day biopsies were more often performed in younger patients (55 vs 65 years) with a history of breast cancer (58.9% vs 30.0%), BRCA mutation (4.5% vs 0.8%), clinical symptoms (17.9% vs 10.0%), or a BI-RADS 5 lesion (2.7% vs 1.7%). No significant difference was observed in the time from biopsy to pathologic diagnosis (2.0 vs 1.7 days, p=.056) or from diagnosis to surgical consultation (11.5 vs 13.4 days, p=.43). The time between diagnostic imaging and surgical consultation was significantly shorter in the same-day group (13.3 vs 26.4 days, p<.001). The time from diagnostic imaging to surgery was shorter in the same-day group, however not statistically significant (37.8 vs 45.8 days, p=.16).
Conclusion: Same-day breast biopsies decreased the time from diagnostic imaging to surgical consultation (p<.001) in symptomatic and high-risk patients and may be valuable to patient care even without a statistically significant effect on time to surgery.
Limitations: Limitations include a small sample size.
Ethics: The United States Institutional Review Board approved this retrospective study with a waiver of informed consent.
Funding: No funding was received for this work.
RPS 1302-14
Association of retrospective peer review and positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsies of breast
Purpose: To evaluate the association between retrospective peer review of breast magnetic resonance imaging-guided vacuum-assisted needle biopsies and positive predictive value of subsequent magnetic resonance imaging-guided biopsies.
Methods: In January 2015, a weekly conference was initiated in our institution to evaluate all breast magnetic resonance imaging-guided vacuum-assisted needle biopsies performed over January 1, 2014-December 31, 2015. During these weekly conferences, 6 anonymised cases were discussed and the faculty voted on whether they agree with the biopsy indication, accurate sampling, and radiology-pathology correlation. We retrospectively compared the magnetic resonance imaging indication, benign or malignant pathology rates, lesion types, and the positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsy in the years before and after initiating this group peer review.
Results: The number of dynamic contrast-enhanced magnetic resonance imaging and magnetic resonance imaging-guided vacuum-assisted needle biopsies before and after initiating the review was 1447 vs 1596 (p=0.0002), and 253 (17.5%) vs 203 (12.7%) (p=0.04), respectively. The positive predictive value of magnetic resonance imaging-guided biopsy significantly increased after group review was implemented (positive predictive value in 2014=9.1 and positive predictive value in 2015=H.8) (p=0.03).
Conclusion: Our study showed an association between retrospective peer review of past biopsies and increased positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsies in our institution.
Limitations: A retrospective study performed in a single institution. The small number of patients included decreased the power of the statistical results. MRI-directed ultrasound and ultrasound guided biopsy rates are not included in this study.
Ethics: This was an institutional review board approved, HIPAA compliant, retrospective case review in which the requirement for patient informed consent was waived.
Funding: No funding was received for this work.


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Tamar Sella (Israel)

European Society of Radiology

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