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University of Colorado Health Sciences Center Denver, CO 80262
I read with interest the paper by Rebner et al. describing their experience with the Advanced Breast Biopsy Instrumentation device (United States Surgical, Norwalk, CT) [1]. Although the conclusion that the procedure may have serious drawbacks follows logically from the data presented, two aspects of this report concern me. First, the discussion, or a modified version of it, might have been more appropriately presented as an editorial. Scientific papers traditionally report data followed by the authors' objective interpretation of the results. The study in question speculates that the disappointing results of the procedure were due in part to the exclusion of breast imagers from the treatment team and decision-making process; this opinion may be valid but is not clearly supported by the paper's data.
Second, the authors' departmental affiliations are not mentioned. (All other scientific papers in the same issue of AJR give departmental affiliations of all authors.) Ideally, departments of radiology, pathology, and surgery would be represented. If no author is a surgeon directly involved with the study, I would be suspicious that both conflict of interest and lack of the authors' surgical expertise may compromise the objectivity and validity of this paper.
Attendees of recent national meetings at which the procedure was discussed by radiologists and surgeons can attest to the intensity of contention surrounding the procedure. This atmosphere calls for objectivity and tact even greater than the high levels usually found in scientific reports.
Reference
William Beaumont Hospital Royal Oak, MI 48073
Henry Ford Hospital Detroit, MI 48202
We thank Dr. Kuni for his interest in our paper [1]. He notes that our discussion speculates that the disappointing results with the Advanced Breast Biopsy Instrumentation (ABBI) device (United States Surgical, Norwalk, CT) are caused in part by the exclusion of breast imagers from the treatment and decision-making process. He states that this opinion is not clearly supported by the data in our paper. We agree that this statement is not well supported in the paper. Although we point out that the positive predictive value of 15.3% is disappointingly low, we do not provide the data that show this value differs significantly from the positive predictive value of all our other breast biopsies in which the radiologist is directly involved in the procedure (sonography and stereotactic-guided core biopsies and needle localization excisional biopsies). That data should have been included in the paper to strengthen our objective interpretation of the results.
Kuni points out that our departmental affiliations (all diagnostic radiologists) were not included in the paper—an important, unintentional oversight. We agree with his observation. However, we disagree with his statement that the lack of a surgeon coauthor compromises the objectivity and validity of the paper. The parameters analyzed were specifically defined and not open to our subjective interpretation. They were tabulated retrospectively from the electronic medical record of aborted procedures and complications reported by the surgeons; the pathologists' reports of lesion size, histologic diagnosis, and margin status; and the participating radiologist's report of conversion from an ABBI procedure to core biopsy and specimen radiograph interpretation. Our data are consistent with other published series that note either a high number of complications or lesions not amenable to a successful ABBI procedure [2].
Our radiology and surgery departments mutually agreed to objectively assess the potential of the ABBI device. Extensive planning and coordination took place between both departments. Both surgeons and radiologists wondered if this technique would benefit our patients. As in Liebman's study, radiologists were available to the surgeons for imaging assistance [3]. However, only in rare cases did the surgeons request assistance from the mammographers. The surgeons, not the radiologists, performed the procedures. No conflict of interest was present on either side.
Most surgeons who initially performed ABBI biopsies no longer perform the procedure. In a commentary [2] dealing with a previous article on the ABBI device [3], Lieberman states, "Their findings and the published experiences of other investigators point out important limitations of the ABBI biopsy procedure...." Moreover, in another paper, Liebman et al. [3] also conclude, "In summary, our experience with the ABBI suggests that it offers little advantage for either malignant or benign lesions." Given our own considerable experience and that of radiologists in several other published series, we maintain that because of the high number of complications and technical failures, the inability to consistently provide tumor-free margins for malignant lesions, the significant postprocedural scarring, and the higher costs, the ABBI device offers no benefit over current existing imaging-guided percutaneous biopsy methods [4].
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