Benign Papillomas of the Breast Diagnosed on Large-Gauge Vacuum Biopsy compared with 14 Gauge Core Needle Biopsy - Do they require surgical excision?

To evaluate whether biopsy with vacuum-assisted biopsy (VAB) devices improves histologic underestimation rates of benign papillomas when compared to smaller bore core needle biopsy (CNB) devices. Patients with biopsy-proven benign papillomas with surgical resection or minimum 12 months follow-up were selected. Two breast pathologists reviewed all pathology slides of percutaneous and excisional biopsy specimens. Histologic underestimation rates for lesions biopsied with 10-12 Gauge (G) VAB were compared to those with 14G CNB. A total of 107 benign papillomas in 107 patients from two centers were included. There were 60 patients (mean age 57 years, SD 10.3 years) diagnosed with VAB and 47 patients (mean age 57.6 years, SD 11.3 years) with 14G CNB who underwent surgical excision or imaging follow-up. The upgrade rate to ductal carcinoma in situ or invasive carcinoma was 1.6% (1/60) with VAB and 8.5% (4/47) with 14G. Upgrade to atypia was 3.3% (2/60) after VAB and 10.6% (5/47) with CNB. The total underestimation rates were 5% (3/60) with VAB and 19.1% (9/47) with CNB. The odds of an upgrade to malignancy was 5.5 times higher with a 14G needle than VAB (95% CI: 0.592-50.853, p = 0.17). We observed a lower but not statistically significant upgrade rate to malignancy and atypia with the use of the 10-12 G VAB as compared with 14G CNB. When a papilloma without atypia is diagnosed with vacuum biopsy there is a high likelihood that it is benign; however, if surgical excision is not performed, long-term follow-up is still required.

Breast lesion excision sample (BLES biopsy) combining stereotactic biopsy and radiofrequency: is it a safe and accurate procedure in case of BIRADS 4 and 5 breast lesions?

The aim of this study was to evaluate the accuracy and safety of breast lesion excision system (BLES) procedure with an Intact system device, under stereotactic and ultrasound guidance. Retrospective data review of 32 breast lesions BI-RADS 4 or 5 underwent Intact procedures, from March 2010 to January 2012. Underestimation rates of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were evaluated; percentage of complete radiologic and histologic removal of the breast lesion were analyzed, as were the complications due to procedure. Complete radiologic excision of the target lesion was achieved in all masses and 58.6% of calcifications. Lesion size was less than 11 mm (mean size 5.6 mm). Underestimation of ADH and DCIS was 0% and 10%, respectively. Low complication rate was noted: only one hematoma. BLES appears an accurate and safe biopsy system for sampling nonpalpable breast lesions, especially in case of microcalcifications clusters categorized as BI-RADS 4 and 5.

[B3 lesions of the breast: histological, clinical, and epidemiological aspects : Update]. / B3-Läsionen der Mamma: Histologische, klinische und epidemiologische Aspekte : Update.

B3 lesions of the breast are a heterogeneous group of lesions with uncertain malignant potential encompassing a broad spectrum of histologically distinct alterations that often pose challenging decisions if diagnosed on the preoperative core or vacuum biopsies. B3 lesions are mostly detected due to mammographic calcifications or mass lesions and, in most cases, encompass a spectrum of atypical lesions such as atypical ductal hyperplasia, classic lobular neoplasia, flat epithelial atypia, papillomas, fibroepithelial tumors, and rarely other lesions such as mucocele-like lesions, atypical apocrine lesions, and rare stromal proliferations. The use of immunohistochemical stains (estrogen receptors, basal cytokeratin, myoepithelial markers, and stromal marker panel) is useful in the differentiation of these lesions and allowing proper classification. Regarding clinical management of B3 lesions, the radiological-pathological correlation of the given entity plays the most important key element for the proper next diagnostic and therapeutic step.

Clinical management of atypical ductal hyperplasia on vacuum-assisted biopsy of microcalcifications: External validation study of a decision tree selecting patients eligible for surveillance.

BACKGROUND: Atypical lesions found on percutaneous breast biopsy raise specific management issues. The aim of this study was to validate the previous performance of a decision tree defined by Forgeard et al to select a subset of patients at low-risk of surgical diagnostic upgrade that would be eligible for surveillance. METHODS: A consecutive series of 211 patients diagnosed with ADH on vacuum-assisted biopsy (VAB) of clustered microcalcifications alone, then operated in our institution, was reviewed. Histological findings on percutaneous cores were compared with definitive diagnoses on surgical specimens. The rate of cancer underestimation on VAB was analyzed in the four arms and two management attitudes defined in the scheme, using size and quality of microcalcification removal and the number of ADH foci. RESULTS: Ninety-eight women with ADH met the inclusion criteria. Overall, 20 cancers were diagnosed at surgery, showing a malignancy rate of 44% (17/39 patients) in the surgery group and of 5% (3/59 patients) in the surveillance group, which was not significantly different from the 2% rate in the monitored reference group (p > 0.64). The malignancy rate increased significantly with the size of clustered microcalcifications (0% when < 6mm, 17% when between 6mm and 21 mm, 48% when > 21 mm, p < 0001) and the number of ADH foci on VAB (14% when ≤ 2, 45% when > 2, p < 0.005). CONCLUSION: Our results corroborate - within the limits of large confidence intervals - those obtained with the reference decision tree. Due to statistical uncertainty, however, they need to be prospectively validated in a broader series.

MR imaging-guided vacuum assisted breast biopsy: Radiological-pathological correlation and underestimation rate in pre-surgical assessment.

BACKGROUND: Magnetic Resonance(MR) guided percutaneous procedures(MRgVABB) have been developed and largely employed to reduce the need of surgical biopsies for suspicious lesions which can be detected only by MR(MR-only lesion). The present study aims to investigate correlation between imaging, histological features of MRgVABB and surgical specimens of MR-only lesions. METHODS: We retrospectively enrolled 56 patients with a total of 61 lesions. Each finding was defined as Mass-Enhancement(ME) or Non-ME(NME) and classified according to BI-RADS. MRgVABB and surgical data were collected. Concordance between MR, MRgVABB and open biopsy was calculated. Underestimation Rate(UR) of MRgVABB with surgery was obtained. RESULTS: B2 and B5b lesions were statistically associated with NME and ME, respectively. No statistical association was found to B3 nor to B5a with radiological features. UR was 10 %; underestimated lesions were strongly associated with the presence of a ME on MR imaging. Moreover, B3 lesions are associated with higher UR. CONCLUSION: Radiological features should influence patient management aiming to construct a correct diagnostic and therapeutic plan. When MR is prescribed for breast cancer staging for ME-MR-only lesions, we suggest surgical open biopsy instead of MRgVABB when upfront surgery is the treatment of choice.

Flat epithelial atypia: comparison between 9-gauge and 11-gauge devices.

BACKGROUND: This study aimed to establish if women with a diagnosis of flat epithelial atypia (FEA) without residual microcalcifications at stereotactic vacuum-assisted breast biopsy (VABB) could be managed with mammographic follow-up (FU) instead of surgery and to compare 9-gauge and 11-gauge devices. PATIENTS AND METHODS: From October 2003 to January 2011, 2382 VABB procedures were performed (1373 with 11-gauge and 1009 with 9-gauge). We found 121 cases of pure FEA that were surgically treated: 57 with a 9-gauge device (group 1) and 64 with an 11-gauge device (group 2). The underestimation rate (UR) of malignancy for patients without and those with residual microcalcifications for each VABB device was calculated. Differences between groups were analyzed with the Fischer exact test. RESULTS: The overall UR of FEA was 4% (2 of 57) with the 9-gauge device and 8% (5 of 64) with the 11-gauge device. With a 9-gauge device, the UR for patients without residual microcalcifications was 0% (0 of 46), and the UR for patients with residual microcalcifications was 18% (2 of 11). With an 11-gauge device, the UR for patients without residual microcalcifications was 0% (0 of 39), the UR for patients with residual microcalcifications at post-biopsy mammograms was 16% (5 of 25). With a 9-gauge device, 80% (46 of 57) of patients did not have residual microcalcifications after VABB. With an 11-gauge device, 60% (39 of 64) of patients had no residual microcalcifications after VABB. Differences between the 9-gauge and 11-gauge devices were statistically significant (P < .05). CONCLUSION: Women with FEA without residual microcalcifications after VABB can be managed conservatively. Nine-gauge VABB is associated with a lower percentage of residual microcalcifications compared with an 11-gauge device, but it is safe to follow patients with FEA if all calcifications are removed with the core biopsy.