Christine M. Denison

The Utility of Ultrasonographically Guided Large-Core Needle Biopsy Results From 500 Consecutive Breast Biopsies

Five hundred ultrasonographically guided large‐core needle breast biopsies of solid masses were performed in 446 women. Histopathologic results were correlated with imaging findings. Ultrasonographically guided large‐core needle biopsy resulted in diagnosis of malignancy (n = 124) or severe atypical ductal hyperplasia (n = 4) in 128 lesions (26%). In the remaining 372 lesions (74%), ultrasonographically guided large‐core needle biopsy yielded benign pathologic results. Follow‐up of more than 1 year (n = 225), results of surgical excision (n = 50), or both were obtainable in 275 (74%) of the benign lesions. No malignancies were discovered at surgical excision or during follow‐up of this group of benign lesions. There were no complications related to large‐core needle biopsy that required additional treatment. Ultrasonographically guided large‐core needle biopsy is a safe and accurate method for evaluating breast lesions that require tissue sampling.

Factors That Impact the Duration of MRI-Guided Core Needle Biopsy

OBJECTIVE The purpose of our study was to determine which patient-related, target lesion-related, or procedure-related variables impact the duration of MRI-guided core needle breast biopsy. MATERIALS AND METHODS Between July 11, 2006, and September 26, 2007, data were collected for 75 single-target MRI-guided 9-gauge vacuum-assisted core needle biopsy procedures using a grid-guidance technique and performed at a single institution. The following variables were studied: MRI suite occupation time, number of operators, patient age and breast size, target morphology and location, approach to target, equipment used, number of image acquisitions and times the patient was moved in and out of the closed magnet, and occurrence of complications. Statistical analysis was performed using the Students t test, analysis of variance, and Pearsons correlation, with p values < 0.05 considered significant. RESULTS The mean duration was 57.9 minutes (SD, 17.2 minutes; range, 30-109 minutes). None of the patient- or target-related variables significantly impacted the duration, although lesions located in the anterior third of the breast showed a trend to prolong the procedure (p = 0.059). The time to complete a procedure was reduced when the operating radiologist was assisted by a breast imaging fellow-in-training (p = 0.01). Increasing numbers of image acquisitions and times the patient was moved in and out of the magnet significantly lengthened the procedure duration (p = 0.0001 for both). No major complications occurred. Biopsies yielded 16% (12/75) malignant and 84% (63/75) benign diagnoses. CONCLUSION Variables that minimized procedure duration were number of image acquisitions, number of patient insertions or removals from the magnet, and assistance of a breast imaging fellow-in-training. No patient-related or target-related variables impacted procedure time.

Lactating Adenoma: Sonographic Features

Abstract: The lactating adenoma is a benign breast lesion occurring as a palpable mass in pregnant or lactating patients. The ultrasound characteristics of 15 lactating adenomas in 15 patients were reviewed retrospectively. Most of the lactating adenomas in this series (10 of 15) had one or more typically benign features such as circumscribed borders, smooth lobulations, or an echogenic pseudocapsule. The remaining five, however, had features typically associated with malignancy, including irregular, angulated, or ill‐defined margins, or posterior acoustic shadowing.

Spindle Cell Lipoma of the Breast A Case Report

A case of spindle cell lipoma of the breast found on mammography in a 53-year-old woman is presented. This rare type of tumor has been previously reported on only after its presentation as a palpable mass. Radiographically it appears as a well-circumscribed mass. Ultrasonographically it appears as a homogeneously hyperechoic nodule. Histologically these lesions are composed of spindle cells intermingled with adipocytes.

Paget disease of the breast with invasion from nipple skin into the dermis: an unusual type of skin invasion not associated with an adverse outcome.

CONTEXT Paget disease is an uncommon skin manifestation of breast cancer, associated with either invasive carcinoma or ductal carcinoma in situ in the underlying breast. In very rare cases, tumor cells within the epidermis invade through the basement membrane of the skin into the dermis. OBJECTIVES To identify a series of cases of Paget disease with direct dermal invasion and to investigate the clinicopathologic features and outcome. DESIGN Cases were identified during a 6-year period from the files of 2 hospitals. The clinical histories, imaging studies, and pathology reports were reviewed. RESULTS Seven patients were identified, 5 with microinvasion (<0.1 cm) and 2 with 0.2- or 0.3-cm invasive carcinomas in the dermis. No lymphovascular invasion was seen. Sentinel nodes were negative in 3 patients who underwent biopsy. Five patients were treated with breast conservation with radiation. Three patients were at high risk for breast cancer because of prior breast cancer, Li-Fraumeni syndrome, or radiation for Hodgkin disease. The latter 2 patients underwent bilateral mastectomies. Three patients received hormonal therapy and 1 oophorectomy. No patient received chemotherapy. At follow-ups ranging from 4 to 66 months (median, 20 months), there have been no recurrences. CONCLUSIONS Patients with direct dermal invasion from Paget disease had a favorable outcome during the available follow-up period. This type of dermal involvement must be distinguished from locally advanced invasive carcinomas with skin invasion classified as T4b in the American Joint Cancer Commission staging system, as cancers with other types of skin invasion are associated with a poor prognosis.

Image-guided core breast biopsy of ductal carcinoma in situ presenting as a non-calcified abnormality

OBJECTIVE Ductal carcinoma in situ (DCIS) typically presents as calcifications which are detected mammographically. Our aim was to evaluate the less common presentations of ductal carcinoma in situ diagnosed by image-guided core biopsy and correlate with histopathologic diagnoses. METHODS AND MATERIAL Imaging and histopathologic findings were retrospectively reviewed in 11 patients with ductal carcinoma in situ diagnosed at core biopsy that presented as noncalcified radiographic abnormalities. RESULTS Mammography showed non-calcified, circumscribed nodules, ill-defined nodules and architectural distortion. In two patients, no mammographic abnormality was detected. Sonography showed circumscribed, round or oval, solid masses; irregular, heterogeneous masses; and a tubular structure. Histopathologic diagnoses included multiple architectural subtypes and ranged from low to high nuclear grade. CONCLUSION Although image-guided core biopsy diagnosis of ductal carcinoma is typically made when sampling calcifications, DCIS can be diagnosed following biopsy of non-calcified masses or distortion. There is no correlation between histopathologic subtype and radiologic appearance.

Non‐Hodgkin Lymphoma of the Breast: Clinical and Radiologic Presentations

Abstract: We reviewed the clinical presentations, radiologic findings, and histopathologic findings in 18 women with 21 non‐Hodgkin lymphomas involving the breast. Eight patients had primary breast lymphoma, 10 had secondary involvement. Three had bilateral lesions. Thirteen lymphomas (62%) presented as palpable breast masses, and one (5%) as a palpable axillary mass with ipsilateral breast peau ďorange. Seven (33%) were clinically occult and detected on routine mammography. Masses ranged from well‐circumscribed to ill‐defined mammographically, and were all hypoechoic at sonography. Histopathologic diagnoses included diffuse large B‐cell lymphoma in six patients (33%), follicle center lymphoma in five patients (28%), small lymphocytic lymphoma in three patients (17%), nodal marginal zone B‐cell lymphoma in two patients (11%), high‐grade B‐cell, Burkitt‐like lymphoma in one patient (5.5%), and Burkitts lymphoma in one patient (5.5%). The radiologic appearance of breast lymphoma is nonspecific, possessing no pathognomonic or distinguishing features. No correlation was noted between radiologic appearance and histopathologic subtype.?

Complex sclerosing lesions and radial sclerosing lesions on core needle biopsy: Low risk of carcinoma on excision in cases with clinical and imaging concordance

Complex or radial sclerosing lesions (CSL/RSL) are uncommon diagnoses on core needle biopsy with a reported upgrade rate ranging between 0% and 23%. As a result, their management remains controversial. In this study, we sought to determine the rate of malignancy on excision for patients with pure CSL/RSL on core biopsy, and to evaluate future breast cancer risk when CSL/RSL is managed without excision. We retrospectively reviewed 118 cases of CSL/RSL diagnosed on image‐guided breast biopsies between 2005 and 2014 at our institution. Of 98 analyzed patients, 34 (35%) underwent excision and 64 (65%) were observed. Demographic and clinical variables between excision and observation groups were compared. In excised specimens, factors associated with upgrade to malignancy were evaluated. The median age at diagnosis was 49 years (range, 27‐88 years). In the excision group, 3/34 cases were associated with malignancy, an overall upgrade rate of 9%. All malignant cases had core needle biopsies interpreted as discordant and were BIRADS 4B or more on imaging. In the observation group, at a median follow‐up of 2.2 years, 3/64 (5%) patients developed ipsilateral cancers, all of which were distant from the index CSL/RSL. In our series, we report a 9% malignancy rate on excision of BIRADS >4C lesions characterized as CSL/RSL on core biopsy. In patients with concordant biopsies and BIRADS 4A or lower lesions who underwent observation, we found a low rate of subsequent ipsilateral cancers. Further studies are needed to confirm that for CSL/RSL in concordant core biopsies and BIRADS 4A or lower, nonpalpable lesions, observation may be a reasonable alternative to excision.

Essential Components of a Successful Breast Core Needle Biopsy Program: Imaging Modalities, Sampling Techniques, Specimen Processing, Radiologic/Pathologic Correlation, and Appropriate Follow-Up

A successful breast core needle biopsy program provides numerous advantages for patients, radiologists, pathologists, surgeons, biomedical research, and the healthcare system. In order to obtain optimal results, it is essential that multiple healthcare providers and disciplines closely communicate and fully cooperate. The complexity of the process from the detection of a lesion, to biopsy, to ultimate outcome creates many opportunities for error. This chapter is a comprehensive guide for best practices for core needle biopsies. The chapter begins with an explanation of how imaging modalities (mammography, ultrasound, and MRI) detect breast abnormalities and how these findings correlate with pathologic lesions. Types of breast needle biopsies and the resulting specimens are then discussed in conjunction with information necessary to determine radiologic/pathologic correlation by both the radiologist and the pathologist. Recommendations for specimen handling from the removal by the radiologist to the creation of the glass slides by the histotechnologist are included. These topics are followed by optimal practices for identifying, excising, and examining a lesion previously sampled by needle biopsy. Throughout the chapter, commonly seen artifacts and possible pitfalls are discussed and illustrated. The chapter concludes with a review of rare cancer recurrences in needle tracks.