Percutaneous Breast Biopsy by gjjur4356

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									Percutaneous Breast
   Ahmer A. Karimuddin
  General Surgery Rounds
      May 14th, 2004
Patient Selection
Lesion Selection
Post biopsy management
Percutaneous Breast Biopsy
Increasing popularity for assistance in
diagnosis of breast pathology
Shorter procedure times
Less invasive
Less expensive
Less tissue removal
   Better cosmesis
Percutaneous Breast Biopsy
Reduces the need for surgery in women
with benign disease
   Morrow et al., Lynn Sage Breast Center, Ann.
    Surg (2001)
Reduces the number of procedures in
women with malignant diagnoses
   Smith et al., Brigham & Young, Arch. Surg.
Percutaneous Breast Biopsy
Patient Selection
   Most frequently used to evaluate non-
    palpable lesions
   Breast Imaging Reporting & Data System
      Designed by American College of Radiology, NCI,
      CDC, FDA, AMA, ACS and College of American
      Multiply validated and used extensively as a tool
      for quality assurance
Percutaneous Breast Biopsy
   Stereotactic
      Based on principle that a lesion can be better
      sampled with two angled stereotactic images
      Performed with the patient upright or prone
           Best results are obtained with the patient prone
      Used most often for suspicious calcifiations
      Automation has yielded better results
    Percutaneous Breast Biopsy
Investigator/Year   # Cases   Concordance Insufficient   # Passes   Needle

Parker/1991         102       96%           0%           3-4        14G

Elsecrog/1992       100       94%           0%           >5         14G

Gisvold/1994        104       90%           0%           >5         14G

Dronkers/1992       53        91%           6%           2          18G

Parker/1990         102       87%           1%           3-4        18G

Gisvold/1994        56        80%           2%           <5         14G

Dowlatshahi/1991 250          67% - 69%     17%          2-3        20g
Percutaneous Breast Biopsy
Stereotactic Biopsy
   Patient may be prone or upright
   Prone is felt to be the best position
   Digital imaging may improve outcomes
Percutaneous Breast Biopsy
   First automated core biopsy in 1993
   Parker et al., Radiology1993
      181 lesions, automated 14 gauge needle
      100& concordance with surgical results
   Also performed with 11 gauge needle
Percutaneous Breast Biopsy
Ultrasound                    Ultrasound
Advantages                    Disadvantages
   Lack of radiation            Lesion must be
   Use of non-dedicated          visualized on
    equipment                     ultrasound
   Access to the entire
   Real-time visualization
    of the needle
   Multi-directional
Percutaneous Breast Biopsy
Magnetic Resonance Imaging
   Specificity 37% to 97%
   Sensitivity 100%
   Heywang et al., Radiology (1999)
      Done with 14 gauge needle
      Diagnostic accuracy around 98%
   Not possible to biopsy medial breast lesions
   Unable to determine lesion retrieval
   No dedicated MR guided biopsy equipment
Percutaneous Breast Biopsy
Acquisition devices
   Fine needle aspiration
      RDOG V trial
      Adequate sample only in 64% of lesions
      Better used with ultrasound guidance
Percutaneous Breast Biopsy
Acquisition devices
   Automated Core Needles
      67% to 96% concordance
      Best results seen with a 14 gauge needle and a long
      excursion gun
      No insufficient samples observed, if atleast 5 samples taken
      With multiple samples, some may be composed of blood
      Difficult to access small lesions or microcalcifications
      May provide incomplete characterization
      No way to leave a marker behind
Percutaneous Breast Biopsy
Acquisition devices
   Directional vacuum assisted biopsy probes
   Blood can be removed from biopsy cavity
   Tissue can be accessed from a distance from the
    probe rather than line of fire
   Multiple samples from one insertion
   Superior to core biopsy
      Higher rate of lesion acquisition
      More accurate characterization of ADH/DCIS
      Lower rate of underestiation
      Allows placement of clip to mark the site
Percutaneous Breast Biopsy
Acquisition devices
   Advanced Breast Biopsy Instrumentation
   Allows use of cannulas upto 2 cm in size
   The entire lesion may be removed
   Only one-in-five lesions are amenable
   High failure rate (~20%)
   Large volume of tissue removal, with scarring and
   1.1% complication report
   Much higher costs as compared to core biopsy
Percutaneous Breast Biopsy
   Smith et al., Brigham & Young, Arch. Surg. (1997
   Average number of operations in women with
    percutaneous breast biopsies – 1.25
   Average number of operations in women with
    surgically diagnosed cancer – 2.01
   Likelihood of clear margins is also higher in
    percutaneous diagnosis (75 to 100% vs. 45% to 64%)
   Using core biopsy techniques, cost of diagnosis can
    also be reduced
   Lindfors et al. – 23% reduction in marginal cost per
    year of life saved
  Percutaneous Breast Biopsy
Frequency of 1 operation after diagnosis
Author          Percutaneous Surgical
                Biopsy           Biopsy
Jackman et al. 90%               24%
Yim et al.      100%             0%
Liberman et al. 84%              29%
Smith et al.    75%              9%
Lind et al.     90%              38%
Kaufman et al. 79%               21%
Morrow et al.   84%              33%
 Percutaneous Breast Biopsy
Limitations                     Underestimates
   Calcification Retreival        Lesion identified as
   Large volume of tissue          malignant/high-risk, but
    needed, as architecture         incomplete
    needs to be studied             characteriszation
   Rate of calcification          Seen most often with
    retrieval with sufficient       calcifications
    tissue for diagnosis is        ADH – 50%
    around 70%                     DCIS – 20%
   Rate of retrieval can be
    increased with vacuum
    assisted probes
Percutaneous Breast Biopsy
False Negatives             Learning Curve
   2.9 to 10.9%               Higher success rates
   How does it compare         after first 20 cases
    to a cancer miss rate   Epithelial
    of 2% at surgical       Displacement
                               Found in 32% of
                                lesions after core
                               No clinical correlation
Percutaneous Breast Biopsy
Lesion Selection
   Category 0 – further radiological intervention
   Category 1 – normal mammography
   Category 2 – normal mammogram with radiological
   Category 3 – finding which is probably benign, but
    necessitates followup
   Category 4 – suspicious abnormality which
      needs a biopsy
   Category 5 – Cancer
Percutaneous Breast Biopsy
Biopsy is recommended for lesions
classified as category 4 & 5
Category 4 lesions
   Liberman et al., MSK
   33% malignancy rate on biopsy
Category 5 lesions
   Orel et al., U Penn
   90% malignancy rate
Percutaneous Breast Biopsy
   Area of controversy
   Multiple studies, fairly consistent results
   Fahy et al., UC Davis, Arch. Surg. (2001)
      No cost benefit to performing percutaneous breast
      Wire localization may be as cost effective as
      percutaneous breast biopsy, followed by repeat
      surgical excisions
Percutaneous Breast Biopsy
   33% rate of malignancy
   Multiple studies show that a percutaneous
    biopsy obviates the need for a surgical
   Cost savings are fairly significant.
   Fahy et al.
Percutaneous Breast Biopsy
   Probably benign category
   0.5% to 2% frequency of cancer
   Management depends on short-term follow up
   Above is cheaper than mammography (factor
    of 8)
Percutaneous Breast Biopsy
Post Biopsy management?
   Rebiopsy
      9 to 18% of lesions require rebiopsy
      ADH – 50% of lesions referred for biopsy
      Other reasons
          Discordance
          Phyllodes tumor
          Pathological recommendations
      Within lesions for which rebiopsy is recommended,
      cancer was found in 0% to 44%
   Percutaneous Breast Biopsy
Rebiopsy rate after percutaneous biopsy
Investigator    Rebiopsy rate    Malignancy at
                (%)              rebiopsy (%)
Dershaw         18               44
Meyer           14               16
Liberman        10               13
Philpotts       15               14
Philpotts       9                19
Meyer           11               16
Liberman        18               14
Percutaneous Breast Biopsy
Imaging Histological Discordance
   Discordant results in upto 6%
   Rate of malignancy is 0 to 64% in discordant samples
   Surgical excision treatment of choice
Fibroepithelial tumors
   Phyllodes tumors - < 1% of all breast tumors
   50 to 75% are benign
   Most common reason for recommending surgical
   Surgery reveals phyllodes in a third of lesions excised
   Surgical excision recommended for fibroepithelial
Percutaneous Breast Biopsy
Atypical Ductal Hyperplasia
   When found on core biopsy, significant
    concern if lesion is underestimated
   33 to 87% of lesions, when excised surgically
    are found to have cancer (DCIS/Invasive
   Continued controversy as to which features
    on pathology mandate excision
   Surgical excision is mandatory until better
    analysis is available
Percutaneous Breast Biopsy
Lobular Neoplasia (ALH & LCIS)
   9 studies have examined issue of lobular
    neoplasia on CNB
   23 of 126 patients had cancer on surgical
    excision (16 of 70 patients with LCIS and 3 of
    28 patients with ALH)
Percutaneous Breast Biopsy
Percutaneous Breast Biopsy
Liberman et al., MSK, AJR 1997
   If ALH or LCIS, surgical excision
   If radiological discordance, excision
   If other pathology requiring excision is found,
   If it cannot be distinguised from DCIS,
   If found incidentally, with a BIRADS of 3, may
    be followed (?)
 Percutaneous Breast Biopsy
Papillary lesions             Small but definete
   Intraductal papillomas,   chance of atypia
    papillomas with atypia    exists
    or CIS, papillary DCIS
                              Atleast repeat core
    and invasive papillary
    carcinomas                biopsy should be
                              Most prudent to
                              excise all lesions with
                              papillary features
Percutaneous Breast Biopsy
Percutaneous Breast Biopsy
4 studies have examined radial scars
noted on core biopsy
   Lee et al., 4 radial scars, all were excised, 1
    case of DCIS
   Jackman et al., 5 radial scars, 2 revealed
    carcinoma on excision
   Phillpots et al., 7 radial scars, 1 case of ADH
Recommend excision of radial scars to
exclude cancer
Percutaneous Breast Biopsy
Columnar Cell Lesions
   Lesions characterized by columnar epithelial cells
    lining lobular units
   Represent a spectrum from duct adenosis to DCIS
   Brogi & Tan, 2002
       23 cases, surgically excised
       4 DCIS, 4 Invasive CA
   Bonnett et al., 2002
       8 lesions
            1 DCIS, 3 ADH
   No set recommendations, but surgical excision would
    indeed be warranted
Percutaneous Breast Biopsy
Mucocele like lesions
   Mucin containing cysts
   May range from ADH to DCIS
   Hard to distinguish between mucocele vs.
    mucinous (colloid) carcinoma
   Recommendations are to excise lesion to rule
    out DCIS/carcinoma
Percutaneous Breast Biopsy
Percutaneous Breast Biopsy
Percutaneous Breast Biopsy is playing an
ever increasing role in management of
breast lesions noted on screening
Should be viewed as a screening tool, in
keeping with screening mammography
Percutaneous Breast Biopsy

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