Best Practice Guidelines for Breast Imaging, Breast Imaging Society, India: Part—2

Breast imaging is a prerequisite for providing high quality breast health care. Choosing the appropriate investigation is central to diagnosing breast disease in patients who present to health professionals for treatment. These patients present to doctors of different subspecialties as well as to general practitioners in our country. It is important, therefore, to provide uniform guidance to doctors in different healthcare setups of our country, urban and rural, government and private, for optimal management of breast diseases. These guidelines framed by the task group set up by the Breast Imaging Society, India, have been formulated focusing primarily on the Indian patients and health care infrastructures. They aim to provide a framework for the referring doctors and practicing radiologists to enable them to choose the appropriate investigation for patients with breast symptoms and signs. The aim has been to keep this framework simple and practical so that it can guide not only subspecialists in breast care but also help doctors who do not routinely deal with breast diseases, so that breast cancer is not missed. Overall, the aim of this document is to provide a holistic approach to standardize breast care imaging services in India. Part 2 of these guidelines focuses on the best practice principles for breast interventions and provides algorithms for the investigation of specific common breast symptoms and signs. Ultrasound is the preferred imaging modality for image-guided breast interventions due to real-time needle visualization, easy availability, patient comfort and absence of radiation. Stereotactic mammography guided procedures are performed if the lesion is visualized on mammography but not visualized on ultrasound. 14-gauge automated core biopsy device is preferred for breast biopsies although vacuum assisted biopsy devices are useful for biopsy of certain abnormalities as well as for imaging guided excision of some pathologies. MRI guided biopsy is reserved for suspicious lesions seen only on MRI. Algorithms for investigation of patients presenting with mastalgia, breast lumps, suspicious nipple discharge, infections and inflammation of the breast have been provided. For early breast cancers routine use of investigations to detect occult distant metastasis is not advised. Metastatic work up for advanced breast cancer is required for selection of appropriate treatment options.

The Effectiveness of Dexmedetomidine in Vacuum-Assisted Breast Biopsy Under Monitored Anesthesia Care / 고신대학교의과대학학술지

OBJECTIVES: Vacuum-assisted breast biopsy (VABB) is a widely used technique for the diagnosis of breast lesions. It is carried out with local anesthesia, but procedural pain and stress are still problematic. Dexmedetomidine is a α-2 receptor agonist that can sedate without significant respiratory depression. The study aimed to report the effectiveness of sedation with monitored anesthesia care (MAC) using dexmedetomidine in VABB. METHODS: This was a retrospective chart review of patients who received VABB under MAC with dexmedetomidine. Forty-seven patients during the period of February 2015 to July 2016 were included. We collected data on patient characteristics, infusion drug and dose, induction to incision time, anesthetic, operation, and recovery time and other complications and vital signs. RESULTS: The mean operating time was 50.1 ± 24.9 minutes, and the anesthetic time was 71.2 ± 28.3 minutes. The mean time from induction to incision was 17.0 ± 5.2 minutes, and the recovery time was 20.1 ± 10.3 minutes. None of the patients needed an advanced airway management. Further, none of them showed hemodynamic instability. CONCLUSIONS: VABB was successfully performed with MAC using dexmedetomidine, and there was no respiratory depression or hemodynamic instability.

Experiencia inicial en biopsias mamarias bajo guía mamográfica digital con sistema de vacío / Initial experience with vacuum assisted breast biopsies under stereotactic guidance

Objetivos Describir la experiencia inicial en el uso de un sistema de biopsia por vacío con guía estereotáxica digital para lesiones mamarias. Material y método Se evaluaron retrospectivamente las biopsias bajo estereotaxia mamográfica con sistema de vacío (bav) realizadas en el Centro de Imagenología Mamaria (imad) de la ciudad de Bahía Blanca desde marzo de 2016 a julio de 2017. En el período analizado, se recibieron 329 pedidos de punción, de los cuales 112 correspondieron a biopsias bajo estereotaxia mamográfica con sistema de vacío y 217 a biopsias bajo ecografía. Se realizaron 99/112 (89%) bav, no pudiéndose completar el procedimiento en 13/112 (11%) de los casos. Resultados Se obtuvieron los siguientes resultados patológicos: 20% (20/99) Maligno, 7% (7/99) Alto riesgo y 73% (72/99) Benigno. Se produjeron complicaciones leves que no requirieron ningún tipo de tratamiento posterior en el 8% de los casos: 7/99 reacción vasovagal y 1/99 dolor que dificultó el procedimiento, aunque en todos los casos se pudo finalizar el mismo. Conclusiones Se diagnosticaron lesiones malignas o de alto riesgo en el 27% de los procedimientos realizados.

Objectives To describe our initial experience with vacuum assisted breast biopsies under stereotactic guidance for non-palpable lesions. Materials and method We retrospectively review the vacuum assisted breast biopsies performed at Centro de Imagenología Mamaria (imad) between march 2016 and july 2017. 329 patients requested a breast biopsy. Of them, 112 were vacuum assisted biopsies under stereotactic guidance and 217 were ultrasound guided. We succesfully completed 99/112 (89%) of vacuum assisted biopsies, not being able to reach the target in the remaining 11%. Results The following pathological results were obtained: 20% (20/99) Malignant, 7% (7/99) High risk and 73% (72/99) Benign lesions. Minor complications, which did not require any further treatment, occurred in 8% of cases: 7/99 vasovagal reactions, 1/99 pain during the procedure. Conclusions Malignant and high-risk lesions were diagnosed in 27% of the procedures performed.

Hemostasis with balloon urinary catheter after vacuum-assisted breast biopsy / 中华内分泌外科杂志

Objective To evaluate the hemostasis effect of balloon urinary catheter after vacuum-assisted breast biopsy (VABB).Methods From May.2016 to May.2017,270 patients undergoing VABB were randomized into study group (135 cases) and control group (135cases).Patients in the study group received VABB postoperative indwelling catheter balloon hemostasis,while patients in the control group received VABB postoperative conventional thoracic pressure bandage to stop bleeding.Postoperative bleeding and hematoma were recorded and compared between the two groups.Results The rates of postoperative bleeding and hematoma in the study group were significantly lower than that in the control group (6.7％ vs 16.3％,P＜0.05;8.9％ vs 24.4％,P＜0.05).Among patients with lesions ≤ 1.5 cm,the rates of postoperative bleeding and hematoma were 1.6％ and 4.7％ in the study group,and 6.5％ and 8.1％ in the control group.There was no significant difference between the two group (P＞0.05).Among patients with lesions ＞1.5 cm,the rates of postoperative bleeding and hematoma in the study group were significantly lower than those in the control group (11.3％ vs 24.7％,P＜0.05;12.7％ vs 32.9％,P＜0.05).Conclusion Hemostasis with balloon urinary catheter is a safe and effective method for postoperative bleeding and hematoma control after VABB.

Long-Term Follow-Up Result of Benign Phyllodes Tumor of the Breast Diagnosed and Excised by Ultrasound-Guided Vacuum-Assisted Breast Biopsy / 한국유방암학회지

PURPOSE: Percutaneous removal of benign breast tumors using ultrasound-guided vacuum-assisted breast biopsy (VABB) has been recently regarded as a feasible and safe method without serious complications. The aim of this study was to evaluate the efficacy and safety of the VABB in the treatment of benign phyllodes tumors, and to identify whether or not surgical re-excision is necessary for benign phyllodes tumors diagnosed and excised by VABB. METHODS: From January 2003 to December 2011, a total of 6,923 VABB were performed in 5,434 patients. Out of 6,923 lesions, 53 were benign phyllodes tumors. Among these, 31 lesions, with a follow-up period of longer than 24 months, were enrolled in this study. Ultrasonography follow-up was performed at 3 to 6 month intervals in order to assess recurrence. The mean follow-up period was 75.9+/-13.5 months (range, 24-94 months). RESULTS: The mean patient age at presentation was 31.6+/-9.4 years. The mean size of the lesion was 1.60+/-0.88 cm. The majority of lesions, 74.2% (23 cases), were palpable, and 25.8% (8 cases) were non-palpable. Twenty-two lesions (71.0%) were classified as Breast Imaging Reporting and Data System category 3, and nine lesions (29.0%) were classified as category 4a, by ultrasonography. During the follow-up period, local recurrence developed in one lesion, making the local recurrence rate 3.2%. CONCLUSION: If a benign phyllodes tumor is diagnosed, and sufficiently excised by VABB, observing the clinical course may be considered as an alternative to performing immediate wide local excision; this is the case despite the fact that it would need to be observed for a prolonged period of time.

The Current Role of Vacuum Assisted Breast Biopsy System in Breast Disease / 한국유방암학회지

The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. However, an excisional biopsy inevitably makes a scar. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. More recently, image-guided percutaneous core-needle biopsy has become a frequently used method for diagnosing palpable and non-palpable breast lesions. Although sensitivity rates for core-needle biopsy are high, it has the disadvantage of histological underestimation, which renders the management of atypical ductal hyperplasia, papillary lesions, and fibroepithelial lesions somewhat difficult. Vacuum assisted breast biopsy (VABB) was developed to overcome some of these negative aspects of core-needle biopsy. VABB allows for a sufficient specimen to be obtained with a single insertion and can provide a more accurate diagnosis and completely remove the lesion under real-time ultrasonic guidance. The advantage of complete lesion removal with VABB is to reduce or eliminate sampling error, to decrease the likelihood of a histological underestimation, to decrease imaging-histological discordance, to decrease the re-biopsy rate, and to diminish the likelihood of subsequent growth on follow-up. In recent years, with the advancement of VABB instruments and techniques, many outcome studies have reported on the use of VABB for resecting benign breast lesions with a curative intent. VABB is highly accurate for diagnosing suspicious breast lesions and is highly successful at treating presumed benign breast lesions. Thus, in the near future, VABB will be routinely offered to all appropriately selected patients.

Is Further Diagnostic Surgery Necessary for the Benign Papillary Lesions that Are Diagnosed by Large Volume Vacuum Assisted Breast Biopsy? / 한국유방암학회지

PURPOSE: There is ongoing controversy regarding the management of papillary lesions that are diagnosed by core needle biopsy (CNB). The development of vacuum assisted biopsy now permits non-operative removal of papillary breast lesions. Our aim was to evaluate whether the papillary lesions diagnosed by vacuum assisted breast biopsy (VABB) can be followed up without further diagnostic excision. METHODS: From January 2003 to July 2009, a total of 4,655 US-guided mammotome excision were performed in 3,714 patients at Kangnam CHA Hospital. Out of 4,655 lesions, 156 lesions were proved to be papillary lesions. Among these, 82 lesions that had histologic findings that were consistent with benign papillary lesions and that were followed up for more than 2 years without further diagnostic surgical excision were collected and retrospectively analyzed. Ultrasonographic follow-up was done at 3-6 month intervals to assess for recurrence. The mean follow up period was 49.6 months. RESULTS: The pathologic diagnoses for the 82 lesions obtained via VABB were benign intraductal papilloma and papillomatosis. Half of the lesions were palpable and 50.0% (41 cases) were nonpalpable. Twenty eight lesions (34.1%) were classified as BIRADS category 3, 50 lesions (61.0%) were category 4A, 3 lesions (3.7%) were category 4B and only 1 lesion (1.2%) was category 5 according to the ultrasound exams. No local recurrence developed during the follow up period that needed surgical re-excision or rebiopsy. None of those diagnosed as benign lesions at VABB were upgraded to a more advanced lesions. CONCLUSION: The benign papillary lesions that are diagnosed and excised by mammotome may not need further diagnostic surgical re-excision if surgeons are sure that the targeted lesions were excised completely.

Ultrasound-guided mammotome excision biopsy for benign breast lesions

OBJECTIVE: A 15-month review of all mammotome excision breast biopsies in the Medical City to evaluate our experience in excising benign breast lesions using this technique by taking into consideration the complications encountered and patient satisfaction regarding the procedure and the postoperative result.METHODS: The study included all patients seen by two breast surgeons of the Medical City Breast Clinic from May 2007 to July 2008 with both palpable breast masses visible on ultrasound with a Breast Imaging Reporting a Data System (BIRADS) classification of 2-4. Women with lesions at high risk for malignancy were excluded from the study. Patient demographics were noted, lesions were classified according to BIRADS classification and data regarding the procedure, compilations incurred and patient satisfaction ratings were obtained.RESULTS: One hundred nineteen patients with ages ranging from 17 to 72 years old underwent ultrasound guided mammotome excision at the TMC-Breast Clinic removing a total of 167 lesions. Majority (82%) of patients were premenopausal whereas 22 (18%) were postmenopausal. Ecchymosis (73%) was the most frequent complication during the procedure due to hematoma formation, pain and a skin nick that require suturing. Of the 25 patients who had a previous open biopsy, 23 (92%) preferred mammotome excision over open breast biopsy.CONCLUSION: Ultrasound-guided mammotome excision is a safe and well-tolerated alternative to open excision biopsy for benign lesions of the breast.

US-guided Vacuum-assisted Breast Biopsy with Air Localization for Patients with Microcalcifications

PURPOSE: Stereotactic vacuum-assisted breast biopsy (SV AB) has recently been introduced as an alternative to the traditional surgical excisional biopsy with needle localization (NLBB). Although SVAB has excellent sensitivity and specificity with very low false negative results, patients might complain about the uncomfortable table and the painful breast compression that is done during SVAB. Furthermore, the cost of SVAB is too expensive to be widely adopted in Korea. So we developed a new technique of vacuum-assisted breast biopsy with air localization (VAB-AL) for the patients suffering with microcalcifications. METHODS: From April 2005 to Oct 2005, 10 microcalcification patients, whose lesions were difficult to be seen on breast ultrasonography, underwent vacuum-assisted breast biopsies with air localization (VAB-AL). First, classical NL was done to localize the mammographic abnormalities. Instead of insertion of the wire, 1 cc amounts of air were injected through a needle. The injected air could be easily visualized as a hyperechogenic density on breast sonography. Vacuum-assisted breast biopsy for the air-induced hyperechogenic densities was then done under sonographic guidance. The specimen radiography was performed to confirm that the lesion was removed. RESULTS: The mean age of the patients was 46 (range: 37~55). The upper-outer quadrant of the breast was the most common site of the lesions (6/10, 60%); the upper-inner quadrant (2/10, 20%), and then the lower-inner quadrant (1/10, 10%) followed. The specimen radiology for all 10 patients showed that the mammographic abnormalities were successfully removed. The most common pathologic type was fibrocystic disease (6/10, 70%); intraductal carcinoma (3/10, 30%), and then atypical ductal hyperplasia (1/10, 10%) followed. There were no major complications. CONCLUSION: Vacuum-assisted breast biopsy with air localization is a new technique that can minimize the complaints of patients with microcalcifications about the uncomfortable table, the painful breast compression and the economic burden of SVAB. This new procedure was successfully performed in our 10 patients, and we believe this procedure shows a lot of promise as one of alternatives to classical NLBB and SVAB.

The Usefulness of US-guided Vacuum-Assisted Breast Biopsy for Probably Benign Lesions

PURPOSE: We wished to determine the usefulness of ultrasound-guided vacuum-assisted biopsy (mammotome) for the removal of the breast lesions that had displayed benign evidence on sonography. METHODS: During an 11 month period, vacuum-assisted breast biopsy was performed for 186 probably benign lesions on sonography using 11-gauge (127 cases) and 8-gauge (59 cases) devices. The age of the patients ranged from 19 to 65 years, and the size of the lesions ranged from 0.4 to 3 cm. We retrospectively analyzed the clinical findings and medical history of the patients who underwent vacuum- assisted breast biopsy, and we then evaluated the complications, the histopathologic results, and the follow-up US findings. RESULTS: Of the 186 cases, the lesions were palpated in 95 cases (51%), and lesions were detected in women during a screening examination in 40 cases (36%), and lesions were detected in women having a history of benign breast biopsy or having a cancer operation in the remaining 18 cases (10%). Severe bleeding during or after the procedures was noted in 4 cases (2.2%). The lesions were pathologically proved as benign in 185 cases and malignant in 1 case. With vacuum-assisted breast biopsy, high-risk benign disease was found in 7 cases, but none of the lesions was pathologically upgraded on the subsequent open surgical biopsy. On the 3-month follow-up US, variable sized hematomas were observed in 6 of 24 cases (25%). We performed incidental treatment on four of the vacuum- assisted breast biopsy patients for nipple discharge that was caused by intraductal papilloma. CONCLUSION: US-guided vacuum-assisted breast biopsy is a minimally invasive, fast and convenient biopsy technique. In addition, it is safe and accurate to use for the histological diagnosis because it would remove all the sonographically demonstrated evidence of a probable benign lesion. This technique can potentially be a useful alternative to some forms of surgical biopsy for the properly selected patients.