Image-guided breast biopsy programme quality evaluation

Image-guided breast biopsies are safe, efficient, and reliable. However, patients are often anxious about these procedures, particularly those who have never undergone a prior biopsy. This prospective IRB-approved study surveyed 163 patients undergoing their first breast biopsy. Participants provided informed consent and completed a short written survey prior to and immediately after their procedure. Level of anxiety as well as anticipated and actual levels of pain prior to and following the procedure were assessed using a 0-10-point Likert scale. Correlation, bivariate, and regression analyses were performed. Regarding the biopsy experience, 133/163 (81.6%) of patients reported it as better than expected. Anxiety decreased significantly from a prebiopsy mean score of 5.52 to a postbiopsy mean score of 2.25 (P < 0.001). Average and greatest pain experienced during the procedure had mean scores of 2.03 and 2.77, respectively, both significantly lower compared to preprocedural expectation (mean 4.53) (P < 0.001). Lower pain scores were reported in US-guided procedures compared to stereotactic- and MRI-guided biopsies (P < 0.001). No significant differences in pain scores were seen in those undergoing single versus multiple biopsies, or when benign, elevated-risk, or malignant lesions were sampled. Positive correlations were seen with prebiopsy anxiety levels and procedural pain as well as with anticipated pain and actual procedural pain. Image-guided biopsies are often better tolerated by patients than anticipated. We stress the benefit of conveying this information to patients prior to biopsy, as decreased anxiety correlates with lower levels of pain experienced during the procedure.

From 1930 to 1990 annual age-adjusted breast cancer death rates for women in the United States remained remarkably constant, oscillating around 32 deaths per 100,000 over 60 years. During this long time-frame, the surgical treatment of breast cancer evolved from radical mastectomy with mandatory lymph node dissection to lumpectomy coupled with radiation therapy. With this new paradigm, lymph node dissection was reserved for women with tumor-invaded axillary lymph nodes. Beginning in the 1970s, chemotherapy after surgery (adjuvant) and before surgery (neoadjuvant) was added to surgical treatment. The radical diminution in the scope of breast surgery did not alter the national breast cancer death rate. Doing less surgery was neither harmful nor beneficial to long-term survival from breast cancer. In the 1980s two events changed this static picture: the addition of tamoxifen to adjuvant and neoadjuvant chemotherapy, and the introduction of mammography. Beginning in 1990 annual breast cancer death rates in the United States began to fall, and have continued to fall each year since then. In 2001, the last year of published statistics, the breast cancer death rate was 26 deaths per 100,000. Best estimates for where to credit this dramatic drop in death rate place approximately 50% of the credit with improved adjuvant chemotherapy and 50% with mammography. Abnormal mammograms demand a breast biopsy since only one in five abnormal mammograms is actually a breast cancer. Consequently, widespread adoption of mammography has produced an image-guided breast biopsy industry in the United States. Open, surgical breast biopsy has been replaced with image-guided breast biopsy because improved breast biopsy tools have made image-guided breast biopsy equivalent in accuracy to open, surgical breast biopsy. These tools, in turn, have changed the professional lives of surgeons, pathologists, and mammographers, leading to the development of dedicated breast surgeons, breast pathologists, and interventional breast radiologists.

To determine the best management option (surgical excision versus imaging surveillance) following the diagnosis of pure radial scars (RSs) and RSs with associated additional high-risk lesions (HRLs) encountered on percutaneous core-needle breast biopsy. An IRB-approved retrospective review of the breast imaging reporting system database was performed to identify all cases of pure RS alone or RS plus an additional HRL (papilloma, atypia, lobular neoplasia) diagnosed on core-needle biopsy, from 2007 to 2016, at four breast centers in our institution. Cases with associated malignancy, discordant radiologic-pathologic results, or those lost to follow-up were excluded. The remaining cases were evaluated to determine results of either subsequent surgical excision or long-term follow-up imaging (minimum of two years). Additional data recorded included clinical presentation, breast density, personal and family history of breast cancer, lesion imaging characteristics, and biopsy method. The study cohort included 111 patients with 111 lesions: 56.8% (63/111) with RS alone (pure) and 43.2% (48/111) with RS plus additional HRL(s). Out of the 63 radiologic-pathologic concordant pure RSs, there were no upgrades to malignancy in 51 subsequent surgical excisions or 12 long-term surveillance cases (0/63, 0%). Out of the 48 RSs plus additional HRL(s), there were 2 upgrades to malignancy (2/48, 4.2%). Cases of radiologic-pathologic concordant pure RS diagnosed at core-needle biopsy do not require surgical excision. On the other hand, surgical excision should be considered for RS plus additional HRLs diagnosed at core-needle biopsy.

The purpose of this study was to evaluate our initial experience with gamma imaging-guided vacuum-assisted breast biopsy in women with abnormal findings. A retrospective review of patients undergoing breast-specific gamma imaging (BSGI), also known as molecular breast imaging (MBI), between April 2011 and October 2015 found 117 nonpalpable mammographically and sonographically occult lesions for which gamma imaging-guided biopsies were recommended. Biopsy was performed with a 9-gauge vacuum-assisted device with subsequent placement of a titanium biopsy site marker. Medical records and pathologic findings were evaluated. Of the 117 biopsies recommended, 104 were successful and 13 were canceled. Of the 104 performed biopsies, 32 (30.8%) had abnormal pathologic findings. Of those 32 biopsies, nine (28.1%) found invasive cancers, six (18.8%) found ductal carcinoma in situ (DCIS), and 17 (53.1%) found high-risk lesions. Of the 17 high-risk lesions, there were three (17.6%) lobular carcinomas in situ, five (29.4%) atypical ductal hyperplasias, two (11.8%) atypical lobular hyperplasias, one (5.9%) flat epithelial atypia, and six (35.3%) papillomas. Two cases of atypical ductal hyperplasia were upgraded to DCIS at surgery. The overall cancer detection rate for gamma imaging-guided biopsy was 16.3%. In this study, gamma imaging-guided biopsy had a positive predictive value of total successful biopsies of 16.3% for cancer and 30.8% for cancer and high-risk lesions. Gamma imaging-guided biopsy is a viable approach to sampling BSGI-MBI-detected lesions without sonographic or mammographic correlate. Our results compare favorably to those reported for MRI-guided biopsy.

To determine the rate of canceled magnetic resonance (MR) imaging-guided breast biopsies due to nonvisualization of the lesion and to assess associated features and outcome data for these cases. With the approval of the institutional review board, a HIPAA-compliant retrospective review, in which the requirement for informed consent was waived, was performed for 907 patients scheduled for MR imaging-guided breast biopsy from 2004 to 2008. In 70 patients, MR imaging biopsy was canceled due to lesion nonvisualization. Medical records and imaging studies were reviewed to identify patient, parenchymal, lesion features and outcome data. Statistical analysis was performed with the Fisher exact test. The 95% confidence interval (CI) was calculated. Cancellation of MR-guided biopsy due to lesion nonvisualization occurred in 8% (70 of 907) of patients and in 8% (74 of 911) of lesions. Factors associated with a significantly higher cancellation rate included marked and moderate versus mild and minimal background parenchymal enhancement (38 of 316 [12%] vs 32 of 591 [5%], P = .001), extremely and heterogeneously dense versus scattered fibroglandular densities and fatty parenchymal volume (64 of 712 [9%] vs six of 195 [3%], P = .006), and lesions 1 cm or less in size (52 of 520 [10%] vs 22 of 391 [6%], P = .02).The rate of cancellation per year was highest in the first year, with a decrease in subsequent years (14 of 102 [14%] vs 56 of 805 [7%], P = .025). A significantly lower rate was found in women with synchronous breast cancer (nine of 240 [4%] vs 61 of 667 [9%], P = .007), and a significantly higher rate was found in women with a history of cancer (35 of 315 [11%] vs 35 of 592 [6%], P = .01). Among 58 women who had MR imaging follow-up, no cancers were identified. Among three women who underwent mastectomy after cancellation, one had ductal carcinoma in situ in the same quadrant as the MR-depicted lesion. The cancer detection rate among 61 women who underwent either MR imaging or pathologic follow-up was 2% (one of 61) (95% CI: 0.4%, 9%). MR imaging-guided breast biopsy was canceled due to lesion nonvisualization in 8% of the patients. Although the cancer detection rate among the lesions for which biopsy was canceled is low (95% CI: 0%, 9%), short-term follow-up MR imaging is prudent.

Introduction: Mammographic density (MD) is a strong breast cancer risk factor; however, the majority of women with high MD have neither a prevalent tumor nor will they develop one in immediate follow-up. Magnetic resonance imaging (MRI) studies suggest that background parenchymal enhancement, an indicator of vascularity, is another strong breast cancer risk predictor. However, it is uncertain how correlated microvessel density (MVD), a histological marker of vascularity, is with MD and if it adds information for disease detection. We therefore investigated relationships between MVD, area and volume measures of MD, and biopsy diagnosis among 218 women referred for image-guided vacuum-assisted breast biopsies. Methods: MVD was determined by counting CD31 (endothelial marker) positive vessels in whole sections of breast biopsies in three areas containing five 40X high power fields. Average MVD per area was calculated and then transformed based on a Box-Cox analysis to approximate a normal distribution. MD volume was quantified using single X-ray absorptiometry (SXA) in digital mammograms and MD area was quantified on the same image using thresholding methods. We used linear regression to evaluate associations between MVD (as the outcome) and MD measures (area and volume) adjusted for age and body mass index (BMI) in the overall population and stratified by biopsy diagnosis: cases (in situ or invasive carcinoma, n = 44) vs. non-cases (non-proliferative or proliferative benign breast disease, n = 174). Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between MVD and biopsy diagnosis (cases vs. non-cases) in models adjusted for age, BMI, and MD measures. Results: MVD was inversely associated with absolute dense area and absolute dense volume in the overall sample (area p = 0.01, volume p = 0.11) and among non-cases (area p = 0.009, volume p = 0.007). In age-, BMI-, and dense area- or dense volume- adjusted logistic regression models, MVD was significantly associated with risk of in situ/invasive disease independent of absolute dense area (OR = 1.16, 95% CI = 1.04, 1.28) and independent of absolute dense volume (OR = 1.16, 95% CI = 1.05-1.29). Conclusion: Our histopathologic analysis suggests that tissue vascularity, as reflected by MVD, may predict breast cancer risk independently of MD, thus providing theoretical support for the potential utility in breast cancer detection of imaging methods that reflect vascularity, such as contrast-enhanced MRI. Citation Format: Ashley S. Felix, Petra Lenz, Ruth M. Pfeiffer, Stephen M. Hewitt, Jennifer Morris, Deesha Patel, Berta Geller, Pamela M. Vacek, Donald L. Weaver, Rachael E. Chicoine, John Shepherd, Amir P. Mahmoudzadeh, Jeff Wang, Bo Fan, Sally Herschorn, Jason Johnson, Louise A. Brinton, Mark E. Sherman, Gretchen L. Gierach. Relationships between mammographic density, microvessel density, and breast biopsy diagnosis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2768. doi:10.1158/1538-7445.AM2015-2768

Lymphocyte transformation in vitro to RIII mouse milk antigen among woman with breast disease

IntroductionWe evaluate diagnostic radiology residents’ perceptions of an ultrasound-guided and stereotactic breast biopsy simulator used at an academic medical center. This simulator is low-cost and easily reproducible. We aim to understand if this simulator improves residents’ self-reported confidence in performing breast biopsy procedures on live patients.MethodsTwenty-eight diagnostic radiology residents were instructed in how to perform ultrasound-guided breast biopsies and stereotactic breast biopsies using real biopsy and imaging equipment, but with tissue models in lieu of live persons. The hands-on experience was preceded by a didactic lecture. The ultrasound-guided tissue model was created with blueberries that were inserted in tofu, and the stereotactic tissue model was created by placing crushed calcium carbonate tablets into cored eggplant. Residents were asked to fill out a survey before and after participating in the simulation, where they self-reported their confidence level at performing ultrasound-guided and stereotactic breast biopsies.ResultsTwenty-eight diagnostic radiology residents participated in the simulation. All residents completed the pre-simulation survey and of these residents, twenty-one completed the post-simulation survey. Prior to the simulation residents reported a median confidence level of 3.5 out of 10 in performing ultrasound-guided breast biopsies, and a median confidence level of 1.0 out of 10 in performing stereotactic-guided breast biopsies. After the simulation, residents reported a median confidence level of 7.0 out of 10 in performing ultrasound-guided breast biopsies, and a median confidence level of 3.0 out of 10 in performing stereotactic-guided breast biopsies. Increases in resident confidence level were statistically significant for both biopsy types (p < 0.01). ConclusionSimulated biopsies can increase the confidence of diagnostic radiology residents that are learning to perform breast biopsies before they perform real biopsies on live patients. Providing simulation training and thereby improving resident confidence may help reduce physician error and patient harm due to poor biopsy techniques.

Image-guided biopsies may be used to diagnose nonpalpable, abnormal findings on a mammogram, ultrasound, or breast magnetic resonance imaging (MRI) study. Historically, image-guided open surgical biopsy was the customary diagnostic approach to these problems. Increasingly, percutaneous biopsy with image guidance is replacing open biopsy as the initial intervention to help plan patient management and, often, to plan definitive surgery. Given the importance of image-guided biopsy and its increasing role in clinical practice, a good understanding of image-guided biopsy options, their advantages and limitations, is an essential component of a breast surgical practice. This chapter will describe percutaneous X-ray, ultrasound and MRI breast needle biopsy techniques, preoperative needle localization, and imaging-pathology correlation while offering a framework for handling more complex situations when both occult and palpable findings coexist.

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as “high-risk” or B3 lesions). Finally, seven frequently asked questions are answered.

Background Use of hormone replacement therapy (HRT) has been associated with increased risk of breast cancer. However relations between use of HRT and benign breast lesions remain contradictory (1-3). Our goal was to investigate whether HRT and its duration use are associated with benign breast lesions. Materials &amp; Methods From 2001 to 2007, 2708 patients with a non palpable breast lesion were referred to our breast care center. Radiological abnormalities were screened either by breast ultrasound mammography, or MRI. Of those, 1 329 patients had a biopsy in our Radiology Unit. We focus on the postmenopausal women (n=739). Clinical data including HRT use extent were reported. Patients with previous history of benign breast disease or malignancy were excluded. Results The analysis was performed on 739 patients. Biopsies yielded a benign result in 414 (56%) of them (fibroadenoma n=71, blunt duct adenosis n=94, fibrocystic disease n=92, epithelial hyperplasia n=56, others n=101), high risk lesions in 57 (8%) (atypical ductal hyperplasia n=28, atypical lobular hyperplasia n=19, lobular carcinoma in situ n=10) and malignancy in 268 (36%) (not studied here). For the 471 patients with benign or high risk breast lesion, the median age was 59 years, 80% had at least one pregnancy and 27% had a family history of breast cancer. Among these 471 patients, 47% of them had used an oral contraceptive and 53% of them a HRT, with a mean duration of use of 2 years. The HRT use was not significantly associated with the type of benign or high risk breast disease. No association was observed either between breast disease and duration of HRT (less or more than 7 years respectively).Older age was significantly correlated to atypia or carcinoma (median age at diagnosis 59 y.o in benign lesions, 60 y.o in high risk lesions and 62 y.o in malign lesions, with significant difference) (p&amp;lt;0,0001). Conclusion In this study of postmenopausal women, HRT and its duration use were not associated with the type of benign or high risk breast lesion. Although a lack of statistical power may be invoked to explain the results, we are called to believe that the magnitude of an effect of HRT use is small, if ever it exists. 1. Finkelde DT, Kitchen PR, Hayes PR, McKinlay MR, Henderson MA 2001 Symptomatic benign breast disease and hormone replacement therapy. Breast 10:127–130 2. Gayet A, Esteve J, Seradour B, Piana L, Jacquemier J 2003 Does hormone replacement therapy increase the frequency of breast atypical hyperplasia in postmenopausal women? Results from the Bouches du Rhone district screening campaign. Eur J Cancer 39:1738–1745 3. Rohan TE, Miller AB 1999 Hormone replacement therapy and risk of benign proliferative epithelial disorders of the breast. Eur J Cancer Prev 8:123–130 Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-10-09.

Optimizing Success and Avoiding Mishaps in the Most Difficult Image-guided Breast Biopsies

We explored the use of a fiber-optic probe for in vivo fluorescence spectroscopy of breast tissues during percutaneous image-guided breast biopsy. A total of 121 biopsy samples with accompanying histological diagnosis were obtained clinically and investigated in this study. The tissue spectra were analyzed using partial least-squares analysis and represented using a set of principal components (PCs) with dramatically reduced data dimension. For nonmalignant tissue samples, a set of PCs that account for the largest amount of variance in the spectra displayed correlation with the percent tissue composition. For all tissue samples, a set of PCs was identified using a Wilcoxon rank-sum test as showing statistically significant differences between: 1) malignant and fibrous/benign; 2) malignant and adipose; and 3) malignant and nonmalignant breast samples. These PCs were used to distinguish malignant from other nonmalignant tissue types using a binary classification scheme based on both linear and nonlinear support vector machine (SVM) and logistic regression (LR). For the sample set investigated in this study, the SVM classifier provided a cross-validated sensitivity and specificity of up to 81% and 87%, respectively, for discrimination between malignant and fibrous/benign samples, and up to 81% and 81%, respectively, for discriminating between malignant and adipose samples. Classification based on LR was used to generate receiver operator curves with an area under the curve (AUC) of 0.87 for discriminating malignant versus fibrous/benign tissues, and an AUC of 0.84 for discriminating malignant from adipose tissue samples. This study demonstrates the feasibility of performing fluorescence spectroscopy during clinical core needle breast biopsy, and the potential of this technique for identifying breast malignancy in vivo.

Introduction: Percutaneous image-guided biopsy is the procedure of choice for diagnosing suspicious abnormalities on breast imaging. Stereotactic, ultrasound, and magnetic resonance imaging are used for image-guided breast biopsies. Stereotactic guidance uses mammography to localize lesions and facilitate placement of a core biopsy needle. The first systems used a vertical-approach needle insertion. The lateral arm device, which is the most recent advancement in stereotactic biopsies and pre-surgical localization allows procedures to be performed using a needle insertion parallel to the compression plate. Areas covered: The lateral arm device was introduced to the market in 2007 and is the first device of its kind. In this article we review the mechanism of this device, the risks and benefits of the device and other the different other modalities utilized to biopsy and localize the breast. We summarize the current literature on this device along with our own experiences utilizing this device. Expert opinion: The lateral arm device has changed the face of stereotactic-guided breast biopsies and localizations by allowing a new approach to perform these procedures. It has improved care to patients by allowing us to get to areas previously not within the biopsy window, decreased biopsy time and increased patient throughput.

&lt;div&gt;Abstract&lt;p&gt;&lt;b&gt;Background:&lt;/b&gt; Mammographic density (MD), the area of non–fatty-appearing tissue divided by total breast area, is a strong breast cancer risk factor. Most MD analyses have used visual categorizations or computer-assisted quantification, which ignore breast thickness. We explored MD volume and area, using a volumetric approach previously validated as predictive of breast cancer risk, in relation to risk factors among women undergoing breast biopsy.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Methods:&lt;/b&gt; Among 413 primarily white women, ages 40 to 65 years, undergoing diagnostic breast biopsies between 2007 and 2010 at an academic facility in Vermont, MD volume (cm&lt;sup&gt;3&lt;/sup&gt;) was quantified in craniocaudal views of the breast contralateral to the biopsy target using a density phantom, whereas MD area (cm&lt;sup&gt;2&lt;/sup&gt;) was measured on the same digital mammograms using thresholding software. Risk factor associations with continuous MD measurements were evaluated using linear regression.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Results:&lt;/b&gt; Percent MD volume and area were correlated (&lt;i&gt;r&lt;/i&gt; = 0.81) and strongly and inversely associated with age, body mass index (BMI), and menopause. Both measures were inversely associated with smoking and positively associated with breast biopsy history. Absolute MD measures were correlated (&lt;i&gt;r&lt;/i&gt; = 0.46) and inversely related to age and menopause. Whereas absolute dense area was inversely associated with BMI, absolute dense volume was positively associated.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Volume and area MD measures exhibit some overlap in risk factor associations, but divergence as well, particularly for BMI.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Impact:&lt;/b&gt; Findings suggest that volume and area density measures differ in subsets of women; notably, among obese women, absolute density was higher with volumetric methods, suggesting that breast cancer risk assessments may vary for these techniques. &lt;i&gt;Cancer Epidemiol Biomarkers Prev; 23(11); 2338–48. ©2014 AACR&lt;/i&gt;.&lt;/p&gt;&lt;/div&gt;