Monica L. Huang

Stereotactic breast biopsy: Pitfalls and pearls

Stereotactic breast biopsies have become indispensable and the standard of care for patients in whom screening mammography or tomosynthesis reveals breast lesions suggestive of malignancy. A variety of stereotactic biopsy systems and needle types are now available, which allow more accurate sampling of lesions as well as successful biopsy of lesions in difficult locations in patients of all body habitus. We discuss how to plan, perform, and follow up stereotactic biopsies. Most importantly, we offer suggestions on how to avoid problems and complications and detail how to achieve technical success even in the most challenging cases. Stereotactic biopsy has proven over time to be an accurate and acceptable alternative to surgical biopsy for histopathologic diagnosis of breast abnormalities. Successful performance of this minimally invasive procedure spares women from undergoing potentially deforming and expensive procedures to diagnose breast disease.

Imaging and pathological findings in a case of invasive squamous cell carcinoma of the breast

A 49-year-old female initially presented to her primary care physician with complaint of pain and swelling in her right breast. The primary care physician noted associated erythema and treated the patient for cellulitis. The patient’s symptoms progressed despite antibiotics. She began noticing some nipple inversion and started palpating a mass in her breast. She was referred to a surgeon for further care. On clinical breast examination, the patient was noted to have a palpable, large centrally located mass in the right breast with associated nipple retraction and erythema in the lateral aspect of the breast. No lymphadenopathy was noted in the ipsilateral axillary, infraclavicular, or supraclavicular nodal basins.

Imaging-Concordant Benign MRI-Guided Vacuum-Assisted Breast Biopsy May Not Warrant MRI Follow-Up

OBJECTIVE The follow-up of breast lesions with imaging-concordant benign histopathology results on MRI-guided vacuum-assisted biopsy (VAB) is not currently standardized. We determined the false omission rate of breast MRI-guided VAB with benign histopathology (negative results) to assess whether breast MRI follow-up is needed. MATERIALS AND METHODS The medical records of patients who underwent 9-gauge breast MRI-guided VAB during 2007-2012 were reviewed retrospectively. Lesions with imaging-concordant benign histopathology results from MRI-guided VAB and surgery or 2 years or more of imaging follow-up were included. The false omission rate (1 - negative predictive value; [number of false-negative results / number of negative results]) of MRI-guided VAB was calculated. RESULTS One hundred sixty-nine lesions were included, and 135 had only imaging follow-up (mammography follow-up: range, 17-107 months [median, 52 months]; MRI follow-up: range, 5-95 months [median, 35 months]). Of the 135 lesions with only imaging follow-up, 48 had mammography only (range, 26-86 months; median, 52 months), and 87 had mammography (range, 17-107 months; median, 52 months) and MRI (range, 5-95 months; median, 35 months). Thirty-four lesions had surgical correlation, and there were no cases of imaging-surgical discordance. Four malignancies were later diagnosed in the same breast in which MRI-guided VAB had been performed. One (0.6%) malignancy was invasive ductal carcinoma at 1 cm from the MRI-guided VAB site; it was mammographically detected 24 months after MRI-guided VAB. The other three malignancies developed 4 cm or more from the site of MRI-guided VAB: one ductal carcinoma in situ (DCIS) detected on mammography 12 months after MRI-guided VAB, one DCIS detected on MRI 24 months after MRI-guided VAB, and one Paget disease lesion detected at physical examination 32 months after MRI-guided VAB. CONCLUSION Breast MRI-guided VAB has a low false omission rate. MRI follow-up of lesions with concordant benign MRI-guided VAB histopathology results may not be warranted.

Incremental Cancer Detection of Locoregional Restaging with Diagnostic Mammography Combined with Whole-Breast and Regional Nodal Ultrasound in Women with Newly Diagnosed Breast Cancer

RATIONALE AND OBJECTIVES This study aims to determine if locoregional restaging with diagnostic mammography and ultrasound (US) of the whole breast and regional nodes performed for quality assurance in women with newly diagnosed breast cancer who were referred to a tertiary care center yields incremental cancer detection. MATERIALS AND METHODS An institutional review board-approved retrospective, single-institution database review was performed on the first 1000 women referred to our center in 2010 with a provisional breast cancer diagnosis. Locoregional restaging consisted of diagnostic full-field digital mammography combined with US of the whole breast and regional nodal basins. Bilateral whole-breast US was performed in women with contralateral mammographic abnormality or had heterogeneously or extremely dense parenchyma. Demographic, clinical, and pathologic factors were analyzed. RESULTS Final analyses included 401 women. Of the 401 women, 138 (34%) did not have their outside images available for review upon referral. The median age was 54 years (range 21-92); the median tumor size was 2.9 cm (range 0.6-18.0) for women whose disease was upstaged and 2.2 cm (range 0.4-15.0) for women whose disease was not upstaged. Incremental cancer detection rates were 15.5% (62 of 401) in the ipsilateral breast and 3.9% (6 of 154) in the contralateral breast (P < 0.0001). The total upstage rate was 25% (100 of 401). Surgical management changed from segmentectomy to mastectomy in 12% (50 of 401). The re-excision rate after segmentectomy was 19% (35 of 189). CONCLUSIONS Locoregional restaging with diagnostic mammography combined with whole-breast and regional nodal US that is performed for standardization of the imaging workup for newly diagnosed breast cancer patients can reduce underestimation of disease burden and impact therapeutic planning.

MR Imaging-Guided Breast Interventions. Indications, Key Principles, and Imaging-Pathology Correlation

MR imaging is now routinely performed for breast cancer screening and staging. For suspicious MR imaging-detected lesions that are mammographically and sonographically occult, MR imaging-guided breast interventions, including biopsy, clip placement, and preoperative needle localization, have been developed to permit accurate tissue diagnosis and aid in surgical planning. These procedures are safe, accurate, and effective when performed according to key principles, including proper patient selection, use of appropriate technique, adequate preprocedure preparation and postprocedure patient care, and postprocedure imaging-pathology correlation. Imaging-pathology correlation after MR imaging-guided biopsy is essential to confirm accurate sampling and guide development of a comprehensive management plan.