Malignancy mimic: Suspicious mammographic and sonographic findings post-vacuum-assisted excision biopsy.

Vacuum-assisted excision biopsy (VAEB) provides a safe alternative to surgical excision for selected (low-risk) B3 breast lesions. We report a case of imaging findings that mimicked malignancy in a patient one year post-VAEB. Awareness of this entity is important to prevent misdiagnosis and unnecessary surgical excision.

Radial scar appearances on contrast-enhanced mammography.

With modern technological advances in imaging, radial scars are more frequently encountered in clinical practice. The management of radial scars remains challenging due to associated upgrade to malignancy at excision. Contrast-enhanced mammography (CEM) has a similar sensitivity compared to MRI in addition to lower cost, better availability and fewer contra-indications. CEM is reported to have an overall excellent negative predictive value for malignancy. In this study, imaging of 55 patients with a core biopsy diagnosis of radial scar since the introduction of CEM into local practice was reviewed. Nine patients underwent CEM as part of their diagnostic work-up and these appearances are presented as a pictorial essay to demonstrate enhancement patterns of radial scars on CEM in this cohort and consider how this knowledge may influence management.

Accuracy and precision of contrast enhanced mammography versus MRI for predicting breast cancer size: how "good" are they really?

OBJECTIVE: To evaluate and compare the accuracy and precision of contrast-enhanced mammography (CEM) vs MRI to predict the size of biopsy-proven invasive breast cancer. METHODS: Prospective study, 59 women with invasive breast cancer on needle biopsy underwent CEM and breast MRI. Two breast radiologists read each patient's study, with access limited to one modality. CEM lesion size was measured using low-energy and recombined images and on MRI, the first post-contrast series. Extent of abnormality per quadrant was measured for multifocal lesions. Reference standards were size of largest invasive malignant lesion, invasive (PathInvasive) and whole (PathTotal). Pre-defined clinical concordance ±10 mm. RESULTS: Mean patient age 56 years, 42 (71%) asymptomatic. Lesions were invasive ductal carcinoma 40 (68%) with ductal carcinoma in situ (31/40) in 78%, multifocal in 12 (20%). Median lesion size was 17 mm (invasive) and 27 mm (total), range (5-125 mm). Lin's concordance correlation coefficients for PathTotal 0.75 (95% CI 0.6, 0.84) and 0.71 (95% CI 0.56, 0.82) for MRI and contrast-enhanced spectral mammography (CESM) respectively. Mean difference for total size, 3% underestimated and 4% overestimated, and for invasive 41% and 50% overestimate on MRI and CESM respectively. LOAs for PathTotal varied from 60% under to a 2.4 or almost threefold over estimation. MRI was concordant with PathTotal in 36 (64%) cases compared with 32 (57%) for CESM. Both modalities concordant in 26 (46%) cases respectively. CONCLUSION: Neither CEM nor MRI have sufficient accuracy to direct changes in planned treatment without needle biopsy confirmation. ADVANCES IN KNOWLEDGE: Despite small mean differences in lesion size estimates using CEM or MRI, the 95% limits of agreement do not meet clinically acceptable levels.

Vacuum-assisted excision biopsy for definitive diagnosis of breast lesions of uncertain malignant potential (B3 lesions) on core biopsy - A single centre Western Australian experience.

INTRODUCTION: In Australia, the usual approach to breast lesions where core biopsy returns an uncertain result ("B3" breast lesion) is to perform surgical diagnostic open biopsy (DOB). This is associated with patient time off work, costs of hospital admission, risks of general anaesthesia and surgical complications. The majority of B3 lesions return benign results following surgery. Vacuum assisted excision biopsy (VAEB) is a less invasive, lower cost alternative, and is standard of care for selected B3 lesions in the United Kingdom. Similar use of VAEB in Australia, could save many women unnecessary surgery. The aim of this study was to document our experience during the introduction of VAEB as an alternative to DOB for diagnosis of selected B3 lesions. METHODS: The multidisciplinary team developed an agreed VAEB pathway for selected B3 lesions. Technically accessible papillary lesions, mucocele-like lesions and radial scars without atypia measuring ≤ 15mm were selected. RESULTS: Over a 7 month period, 18 women with 20 B3 lesions were offered VAEB. 16 women (18 lesions) chose VAEB over DOB. Papillomas were the commonest lesion type. All lesions were successfully sampled: 17/18 were benign. One lesion (6%) was upgraded to malignancy (ductal carcinoma in situ on VAEB, invasive ductal carcinoma at surgery). No major complications occurred. Patient satisfaction was high: 15/16 respondents would again choose VAEB over surgery. CONCLUSION: VAEB is a patient-preferred, safe, well-tolerated, lower-cost alternative to DOB for definitive diagnosis of selected B3 breast lesions.

Does breast biopsy marker cost and availability influence utilisation in radiology practice?

INTRODUCTION: Breast Screen Australia and Breast Screen Aotearoa guidelines recommend breast biopsy marker (BBM) use in indicated patients. This study aims to evaluate whether BBM cost and availability impacts BBM utilisation. METHODS: An online survey was disseminated to radiologists who identified 'breast imaging' as their area of practice in the Royal Australian and New Zealand College of Radiologists (RANZCR) customer relationship management system. Survey questions addressed participant demographics and factors relating to BBM use. RESULTS: Most (92%, 245/266) participants report that BBMs are routinely available at their place of practice. Those employed in private practice were more likely to report that BBMs are not routinely available. 22% (58/266) of radiologists report that BBM cost influences choice of biopsy type (core biopsy vs fine needle aspirate), this finding was more frequent in those employed in private practice. 47% of respondents report that the cost of BBMs is passed on to the patient, with all these respondents employed in a private or mixed private/public setting. Half the respondents (133/266) reported that their decision to use BBMs would be influenced by the availability of insurance coverage to cover BBM costs. CONCLUSIONS: Results suggest that BBM cost and availability influences both choice of biopsy type (core biopsy vs FNA) and choice to use a BBM. Radiologists working in private practice or mixed private/public practice report that BBMs are less likely to be available for use, and that BBM cost is more likely passed to the patient; possibly disadvantaging patients who present to private radiology providers with imaging findings or conditions that would indicate BBM insertion under current national guidelines.

Evaluating breast biopsy practice and breast biopsy marker utilisation in the clinical setting.

INTRODUCTION: Breast Screen Australia and Breast Screen Aotearoa guidelines recommend breast biopsy marker (BBM) use in indicated patients. This study aims to evaluate breast biopsy practice and BBM utilisation by modality. METHODS: An online survey was disseminated to radiologists who identified 'breast imaging' as their area of practice in the Royal Australian and New Zealand College of Radiologists (RANZCR) customer relationship management system. Survey questions addressed participant demographics and factors relating to BBM use. RESULTS: Most respondents (72%) place between 1 and 4 BBMs per week. Almost all (99%) respondents perform ultrasound-guided biopsy of the breast or axillary nodes, with 85% performing stereotactic or tomosynthesis-guided breast biopsy and 27% performing MRI-guided breast biopsy. BBM utilisation differs by modality, with 97% respondents always placing a BBM post-MRI-guided breast biopsy, 50% always placing a BBM post-stereotactic-guided biopsy and 3% always placing a BBM post-ultrasound-guided breast biopsy. CONCLUSIONS: Almost all radiologists perform breast biopsy using ultrasound, stereotactic/tomosynthesis or MRI guidance. BBM utilisation varies by modality, with 72% of respondents placing between 1 and 4 clips per week. Reasons for placing or not placing BBM aligned with prior studies. This is the first study to evaluate the number of breast biopsies performed by radiologists on a weekly or monthly basis, providing a useful platform for comparison in the local setting.

Pre-operative localization of impalpable breast lesions using iodine 125 seeds: Placement accuracy and multidisciplinary challenges.

INTRODUCTION: The number of impalpable breast lesions requiring pre-operative lesion localization (PLL) continues to increase. The use of Radio-guided Occult Lesion Localization with Iodine 125 Seeds (ROLLIS) offers multiple benefits for the multidisciplinary team (MDT), but is not without challenges. AIMS: The aims of this audit were to review our multidisciplinary team's experience following introduction of ROLLIS as standard of care for PLL, identify challenges and evaluate seed placement accuracy (SPA). RESULTS/OUTCOMES: Over a nineteen month period, 327 seeds were inserted: 96% of single seed localizations were within 10 mm, 91% within 5 mm and 42% within or in contact with the lesion (or marker clip surrogate) on post-insertion two view mammography. Each component of the MDT reported on benefits of the ROLLIS program and challenges faced. Examples included: an undetectable seed in the operating room, a seed damaged in pathology during specimen processing, suboptimal seed position requiring hook-wire localization (HWL) and delayed seed removal in a patient who initially refused to return for surgery. CONCLUSION: ROLLIS results in high seed placement accuracy. Despite clear advantages, use of ROLLIS presents some multidisciplinary challenges. Robust patient information, training of new staff and adherence to strict policies and protocols are required to ensure safe delivery of a ROLLIS program.

Are breast biopsy markers underused?

INTRODUCTION: To evaluate current use of breast biopsy markers (BBM) amongst Australian and New Zealand radiologists. METHODS: Radiologists attending a national breast conference were invited to complete an online survey addressing demographics, BBM use following ultrasound, stereotactic, tomosynthesis and MRI-guided biopsy, frequency of early BBM displacement, preoperative lesion localisation (PLL) and axillary BBM use. RESULTS: Overall response rate was 52% (60/115). The majority (n = 45) 75% practiced in Australia. 98% had BBMs available in their practice, 40% reported BBM costs weren't covered by insurance. 27% would use BBMs more often if they were, with some utilising smaller gauge devices for lesion sampling to minimise need for BBM use and patient out-of-pocket costs. Ultrasound-guided procedures were associated with lower rates of clinically significant BBM displacement (P = 0.001). Considering PLL, 44% were able to perform US-guided PLL in <25% of cases. Poor sonographic visibility was the commonest reason why this wasn't possible. In the axilla, BBMs were mainly used to mark positive nodes in pre-neoadjuvant chemotherapy patients. CONCLUSION: This survey is the first to provide data on BBM use amongst a sample of predominantly Australian and New Zealand radiologists, and provides compelling evidence of significantly lower incidence of BBM displacement with US-guided procedures. Our results suggest some radiologists may hesitate to use BBMs due to cost, and this can influence their choice of biopsy technique. Provision of a Medicare item Number for BBMs may lead to increased adoption of best practice guidelines for preoperative diagnosis of breast lesions.

Radiographer technique: Does it contribute to the question of clip migration?

INTRODUCTION: Marker clips are commonly deployed at the site of a percutaneous breast biopsy. Studies have shown that displacement of the clip from the site of deployment is not uncommon. The objective of this study was to determine how much 'migration' could be seen with fixed structures within the breast tissue across three consecutive annual screening examinations, and therefore attempt to quantify how much of the reported clip migration could be due to radiographer technique. METHODS: Large, easily identified benign calcifications were measured by two investigators across three consecutive cycles of screening mammography. The position of the calcifications on the two standard mammographic views was measured in two planes. Other variables recorded included breast size and density, compression force used, and location of the benign calcifications within the breast. RESULTS: In 38% of cases, benign breast calcifications showed a mimicked movement of >15 mm in at least one plane. This was greatest in large breasts, those where fibroglandular tissue occupied less than 50% of the breast volume, and in the upper outer quadrant of the breast where mimicked movement >10 mm was noted in up to 90% of the larger breasts. CONCLUSION: Fixed immobile objects in the breast can appear to move a distance of >15 mm in up to 30% of cases. Clinically, some of what has previously been called marker 'migration' may be spurious and accounted for by differences in radiographic positioning techniques.