Utility of short-interval follow-up mammography after a benign-concordant stereotactic breast biopsy result.

BACKGROUND: There is currently no clear consensus recommendation for the use of short-interval follow-up mammography after a benign-concordant breast biopsy (BCBB), and practice patterns vary widely. The objectives of this study were to evaluate whether a short-interval follow-up mammogram provided clinical utility after stereotactic BCBB and to examine the costs associated with this surveillance strategy. METHODS: A retrospective review of women who underwent a stereotactic breast biopsy yielding benign-concordant results between January 2005 and October 2014 was performed to evaluate findings on subsequent imaging, to calculate compliance with recommended short-interval imaging, and to examine whether subsequent imaging revealed an abnormality at the site of the initial stereotactic BCBB. A cost analysis was performed utilizing Medicare reimbursement rates to calculate projected and actual costs of short-interval follow-up imaging after stereotactic BCBB. RESULTS: Of the 470 stereotactic BCBB performed, a short-interval mammogram was completed in 207 (44.0%), 9 (4.3%) of which had suspicious mammographic findings at the initial biopsy site, and 6 subsequently underwent biopsy, with none resulting in malignant or high-risk pathology. The cost of short-interval mammographic follow-up (n = 207) was calculated at $28,541.16. CONCLUSIONS: This study provides evidence that 6-month follow-up mammography has low clinical utility and unnecessarily increases costs after stereotactic BCBB. A safe and more cost-effective strategy may be resumption of routine mammography at 12 months post-biopsy.

A prospective clinical study to evaluate the safety and performance of wireless localization of nonpalpable breast lesions using radiofrequency identification technology.

OBJECTIVE: The purpose of this study was to evaluate the safety and performance of localizing nonpalpable breast lesions using radiofrequency identification technology. SUBJECTS AND METHODS: Twenty consecutive women requiring preoperative localization of a breast lesion were recruited. Subjects underwent placement of both a hook wire and a radiofrequency identification tag immediately before surgery. The radiofrequency identification tag was the primary method used by the operating surgeon to localize each lesion during excision, with the hook wire serving as backup in case of tag migration or failed localization. Successful localization with removal of the intended lesion was the primary outcome measured. Tag migration and postoperative infection were also noted to assess safety. RESULTS: Twenty patients underwent placement of a radiofrequency identification tag, 12 under ultrasound guidance and eight with stereotactic guidance. In all cases, the radiofrequency identification tag was successfully localized by the reader at the level of the skin before incision, and the intended lesion was removed along with the radiofrequency identification tag. There were no localization failures and no postoperative infections. Tag migration did not occur before incision, but in three cases, occurred as the lesion was being retracted with fingers to make the final cut along the deep surface of the specimen. CONCLUSION: In this initial clinical study, radiofrequency tags were safe and able to successfully localize nonpalpable breast lesions. Radiofrequency identification technology may represent an alternative method to hook wire localization.

Excisional biopsy of borderline lesions after large bore vacuum-assisted core needle biopsy- is it necessary?

The current recommendation for borderline breast lesions after core needle biopsy is for surgical excision due to a high rate of pathologic underestimation. With the use of vacuum-assisted core needle (VACN) biopsy devices, upgrade rates have improved, but still average 20 per cent. We routinely use larger bore VACNs (7- and 8-gauge) than previously reported (9 to 11-gauge). The aim of this study is to evaluate the upgrade rate to malignancy in patients undergoing VACN using larger bore needles. VACN biopsies were performed in 902 patients. Of those, 87 were recommended excisional biopsy for borderline or noncorrelating lesions and 66 underwent the procedure. Two patients were upgraded to cancer, for an overall upstage rate of 3 per cent. Both of these underestimations were in patients that initially had atypical ductal hyperplasia. In the patients not excised, no patient developed further cancer. A 7- or 8-gauge needle was used in 57 per cent of patients, greater than 90 per cent removal of the initial lesion was accomplished in 53 per cent of cases, and there were no bleeding complications. This study suggests that upgrade rates decline with larger bore biopsy needles with near complete excision of the initial lesion, and that some borderline lesions may potentially be managed nonoperatively.

Evaluation of three scoring systems predicting non sentinel node metastasis in breast cancer patients with a positive sentinel node biopsy.

BACKGROUND: Completion axillary lymph node dissection (cALND), performed after a positive sentinel lymph node biopsy (SLNB) in breast cancer patients, often results in no additional positive nodes. Scoring systems have been published to aid in the prediction of nonsentinel node metastasis. Our purpose was to assess the validity of these scoring systems in our patient population. METHODS: For 39 consecutive patients who underwent cALND after a positive SLNB, scores were calculated using retrospective patient data for each of the three scoring systems used. Receiver operating characteristics (ROC) curves were drawn, and the areas under the curves were calculated to assess the discriminative power of each system. Univariate analysis was performed to assess the predictability of individual patient and tumor characteristics. RESULTS: Nonsentinel nodes were positive in 23 (59%) patients. The areas under the ROC curves were 0.63, 0.70, and 0.68, respectively. The proportion of sentinel nodes that were positive and the total number of sentinel nodes retrieved were the only individual predictors of nonsentinel node metastasis. CONCLUSIONS: Given the high incidence of retrieving no additional metastasis on cALND, individualized patient management according to risk is desirable. Scoring systems provide additional information regarding the likelihood of metastasis in nonsentinel nodes, but their predictability remains less than optimal. The use of scoring systems must be applied with caution until future studies provide a more accurate assessment of risk for patients with a positive SLNB.

Percutaneous excisional biopsy of palpable breast masses under ultrasound visualization.

A palpable breast mass is a common reason for surgical consultation. Our goal was to determine whether ultrasound-guided vacuum-assisted core biopsy (US-VACB) is safe and effective in completely removing presumed benign palpable breast masses. We conducted a cohort study of 201 consecutive patients with presumed benign palpable masses who underwent removal with US-VACB. The main outcome measured was the successful removal of palpable masses. Palpable masses were successfully removed with US-VACB in 99% of cases; 2% were cancer and 7.5% were atypical ductal hyperplasia or phyllodes tumor. Two clinical recurrences representing a seroma were seen on follow-up. US-VACB is safe and effective in the initial diagnosis and management of presumed benign palpable breast masses. It provides the benefits of percutaneous biopsy and the palpable abnormality no longer remains.

Intraoperative injection of technetium-99m sulfur colloid is effective in the detection of sentinel lymph nodes in breast cancer.

BACKGROUND: Our objective was to determine if intraoperative injection of technetium-99m-labeled sulfur colloid is as effective as preoperative injection in the detection of sentinel lymph nodes (SLNs). METHODS: Two hundred consecutive patients with breast cancer underwent SLN biopsy examination. Radiocolloid was injected in the preoperative area (group A) or immediately after induction of anesthesia in the operating room (group B). RESULTS: The SLN detection rate was similar for groups A (96%) and B (100%; P = .2). Radioactive SLNs were detected in 95% of patients in group A and in 97% of patients in group B (P = .1). The mean number of SLNs harvested was 1.6 and 2.1 for groups A and B, respectively. There was no significant difference in positive SLNs between groups (P = .11). CONCLUSIONS: Intraoperative injection of sulfur colloid is highly effective in the detection of SLNs, avoiding patient discomfort and surgical schedule delays.

Outcomes of clinical and surgical assessment of women with pathological nipple discharge.

There is no consensus about the diagnostic approach to pathologic nipple discharge (PND). We hypothesize that lactiferous duct excision (microdochectomy) or image-guided biopsy are safe and effective means of diagnosis of PND. Eighty-two patients with PND underwent history and physical exam followed by breast sonography and mammogram. Image-guided biopsy was done if imaging studies were positive, whereas microdochectomy was done if normal. Discharge was unilateral (96%), bloody (79%), and spontaneous (62%). The sensitivity, specificity, positive and negative predictive values for the detection of neoplasia were 0.07, 1.0, 1.0, and 0.4 for mammography and 0.26, 0.97, 0.91, and 0.48 for sonography, respectively. Tissue diagnosis revealed papillary lesion (57%), mammary duct ectasia (33%), breast cancer (5%), and inflammatory/infectious (5%) causes. Hemorrhagic discharge associated with pregnancy or infections was managed successfully without surgery. After a median follow-up of 18 months, no PND recurrence was seen, but one patient developed cancer in a different location after diagnosis of atypical ductal hyperplasia. In conclusion, imaging studies provide confirmatory information and a biopsy target when positive. Negative imaging does not reliably exclude neoplasia or malignancy. Microdochectomy provides a sensible and effective approach in the workup of patients with PND.

Abnormal mammographic findings with short-interval follow-up recommendation.

An abnormal Breast Imaging and Reporting Data System (BIRADS) category 3 mammogram with a short interval follow-up recommendation is a common finding seen in approximately 40% of women for each decade of screening. Factors associated with category 3 mammograms include mammography examination features, tendencies of the interpreting physician, and features of the country's health care system and the screened population including age, family history, previous biopsies, obesity, and menopausal hormone therapy. Recently, the degree to which a BIRADS category 3 mammographic result provides differential breast cancer risk compared with normal mammographic categories (BIRADS category 1 or 2) has been questioned. The yield of category 3 mammographic results could potentially be increased by more uniform performance of additional imaging workup (additional views and/or ultrasonography). In addition, other strategies to more accurately characterize the risk of breast cancer in women with category 3 mammographic results are under evaluation and including magnetic resonance imaging, computer-aided classification systems, and digital tomosynthesis. Given the potential psychologic impact of abnormal mammographic results, studies attempting to more accurately relate screening mammography findings to breast cancer risk are a priority.

Outcomes of surgical and sonographic assessment of breast masses in women younger than 30.

Assessment of breast masses in young women is challenging due to normal glandular variance. Our purpose is to define the outcomes of specialized physical exam, selective breast sonography (BUS), and biopsy in women younger than 30. Five hundred forty-two patients younger than 30 referred with a palpable breast mass were studied. Patients' mean age was 24.8. Surgeon's physical exam confirmed a dominant mass in 44 per cent of cases. Thirty-seven per cent had normal clinical exams. Median tumor size was 2.2 cm. On multivariate analysis, a mass on surgeon's clinical exam (P < 0.0001), and BUS (P = 0.0001) predicted the presence of a true mass. Fifty-three per cent of self-detected abnormalities were true masses compared to 18 per cent when detected by the primary care provider (PCP) (P < 0.001). Most common diagnoses were fibroadenoma (72%), breast cysts (4%), or fibrocystic changes (3%). Malignancy occurred in 1 per cent. In summary, breast mass is a common reason for surgical consultation. Normal glandular nodularity is often mistaken for a mass. However, a judicious approach of physical exam by a surgeon using selective BUS and image guided core biopsy provides an efficient and safe approach for diagnosis. Breast malignancy is a rare but serious cause of breast mass in young women.

Diagnosis of palpable breast masses: ultrasound-guided large core biopsy in a multidisciplinary setting.

Cytologic diagnosis of palpable breast masses is an accepted method for diagnosis. However, the high nondiagnostic rate causes repeat biopsy, unnecessary delays, and increased costs. Our purpose is to evaluate the use of ultrasound (US)-guided large-core needle biopsy as part of the minimally invasive multidisciplinary diagnosis of palpable breast masses. We studied 502 consecutive patients with 510 palpable solid breast masses seen and evaluated by a multidisciplinary team. Patients had US-guided core biopsy. Clinical-imaging-pathologic correlation (CIPC) was done in all cases. Core biopsy was deemed conclusive if CIPC was congruent and was used to guide definitive management. The median age of our patients was 39 years. Median tumor size was 2.2 cm. Of these cases, 463 (91%) had a conclusive diagnosis on CIPC. Core needle findings on 47 masses were nondefinitive to guide therapy (fibroepithelial lesion, atypical ductal hyperplasia, intraductal papilloma, CIPC). Three cancers were detected in this group on excisional biopsy. In conclusion, US-guided large-core needle biopsy is a sensitive method for diagnosis of palpable breast masses. Multidisciplinary correlation of clinical findings, imaging, and pathology is essential for success. This approach improves use of operating room resources and maximizes patient participation in the decision-making process.

Sentinel lymph node mapping of breast cancer: a case-control study of methylene blue tracer compared to isosulfan blue.

Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node. However, allergic reactions may be life threatening. We compared the efficacy of methylene blue dye as a tracer for sentinel lymph node biopsy to isosulfan blue dye. In an analysis of 164 cases, there was no clinical or statistically significant difference in the success rate of sentinel node biopsy (P = 0.22), the number of blue sentinel nodes harvested (P = 0.46), the concordance with radioactive sentinel nodes (P = 0.92), or the incidence of metastases (P = 0.87) when methylene blue tracer was compared to isosulfan blue. No adverse reaction to either blue dye was observed. In conclusion, intraparenchymal injection of methylene blue dye is a reliable tracer for the lymphatic system and nodal identification during sentinel node mapping for breast cancer. It is safe, inexpensive, and readily available.

Outcomes of sonography-based management of breast cysts.

BACKGROUND: Ultrasound is commonly used during diagnosis of breast lesions. Our purpose was to study the role of sonography for risk stratification of malignancy in the diagnosis and management of palpable breast cysts. METHODS: This was a cohort study of 176 patients with palpable breast cysts. Sonographic findings were correlated with clinical and pathologic outcomes. RESULTS: Mean cyst size was 2.0 +/- 1.8 cm. Cysts were simple, complex and probably benign, and complex and suspicious for neoplasm in 82.25%, 10.25% and 7.5% of patients, respectively. Thick cyst wall (P = 0.0001), mural tumor (P <0.00001), eccentric mass (P = 0.034), and internal septae (P = 0.031) were predictive of neoplasm. Of cysts >3 cm, 33% were cancerous (P = 0.000027). After 378 days of follow-up, 26 % of cysts had recurred. Recurrence was more frequent in patients with bilateral or multiple cysts (P = 0.004). CONCLUSIONS: Sonography is useful in risk stratification of malignancy in breast cysts. There is a high risk of recurrence after cyst aspiration.