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ABSTRACT |
Tuesday, May 8, 11:20 AM–12:30 PM
Abstracts 105-111
Moderator(s): Christopher Comstock and Gillian Newstead
11:20 AM
105. Trends in the Diagnosis and Outcome of Atypia on Core Breast Biopsy
Philpotts L. E.; Watson A. N.; Hansen A.* Yale University School of Medicine, New Haven, CT
Address correspondence to A. Hansen (aahansen{at}comcast.net)
Objective: The goal of this study was to assess the trends in the percentage of core biopsies yielding atypia on histology as a function of time, from 1996 through 2005, and to compare the upgrade rates of cancer during the same time period.
Materials and Methods: A retrospective review of the breast imaging biopsy database was performed to identify all cases of atypia diagnosed on core biopsy from 1996–2005 (total cases = 4036). Core biopsies included stereotactic and ultrasound guided procedures. The percentage of cases diagnosed with atypia was calculated for the entire group and for each year. A retrospective search of the breast imaging and pathology databases was performed to correlate surgical pathological results in patients undergoing excision. The underestimation rate of cancer was determined and similarly analyzed for the entire group and per year. Subgroup analysis of types of atypia including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and other atypias was also performed.
Results: The percentage of cases yielding a diagnosis of atypia on core biopsy during the time period was 7% (range 3–10%). The percentage per year has been fairly stable in the last decade ranging from 7% in 1996 to 5% in 2000 to 8% in 2004 cases. On excision, the upgrade rate has shown a progressive decrease during the same time. The overall upgrade rate was 13%. This ranged from 38% in 1996 to 9.5% in 2000 to 4.5% in 2005. For subgroups of atypias, the upgrade rate ranged from 5–40%. Focal or minimal ADH and ALH had to lowest upgrade rates of 5%. Marked or borderline ADH had the highest (40%) and mixed atypias had an upgrade rate of 20%.
Conclusion: While the percentage of cases diagnosed as atypia on core biopsy has remained stable over the past decade, the upgrade rate has markedly decreased. Therefore, more patients are undergoing surgical excision to diagnose fewer cancers. Continued efforts to identify patients in whom surgical excision may not be necessary is strongly encouraged to maintain the benefits of core biopsy.
106. Imaging-Histologic Discordance at MRI-Guided Vacuum-Assisted Breast Biopsy
Lee J.*; Murray M. P.; Liberman L. Memorial Sloan-Kettering Cancer Center, New York, NY
Address correspondence to J. Lee (leej1234{at}mskcc.org)
Objective: The purpose of our study was to determine the frequency of discordance at MRI-guided vacuum-assisted biopsy, and to assess the frequency of cancer among discordant lesions.
Materials and Methods: With IRB approval, retrospective review was performed of a database of 342 lesions that had MRI-guided vacuum-assisted biopsy (VAB) during a 39-month period. Biopsies were performed in a 1.5-T magnet using a 9-gauge MRI-compatible VAB device (ATEC, Suros, Indianapolis, IN). Medical and pathology records were reviewed to determine the number of discordant lesions and subsequent surgical outcome. Statistical analysis was performed.
Results: Among 342 lesions that had MRI-guided VAB, discordant results were encountered in 24 (7%; 95% confidence intervals, 3–14%). These discordant lesions were identified in 24 women of median age 47 (range, 37–65) years. Median MRI lesion size was 1.2 (range, 0.5–8.5) cm; MRI lesion type was mass in 11 (50%) and non-mass in 11 (50%). Discordance was more likely in lesions measuring 2 cm or larger as compared to smaller lesions (16% vs. 4%, p < 0.001). There was a trend toward a higher frequency of discordance in lesions identified in the extent of disease or problem-solving setting as compared to the high-risk screening or follow-up setting (12% vs. 5%, p < 0.06). The likelihood of discordance did not differ significantly as a function of MRI lesion type, menopausal status, or operator experience. Subsequent surgery, performed in 19 discordant lesions, yielded cancer in six (32%; 95% confidence intervals, 13–57%), including ductal carcinoma in situ (DCIS) in two and invasive carcinoma in four (three ductal and one lobular, all with associated DCIS).
Conclusion: Imaging-histologic discordance was encountered in 7% of lesions that had MRI-guided VAB. Among discordant lesions, surgical excision revealed cancer in 32%. Imaging-histologic correlation is essential after MRI-guided VAB, to avoid delay in the diagnosis of breast cancer.
107. Reasons for Cancellation of MR-guided Biopsies: Correlation of Patient and Lesion Characteristics with Likelihood of Biopsy Cancellation
Tredennick T.*; Mainiero M. B.; Lourenco A. P.; Lazarus E. Rhode Island Hospital/Brown Medical School, Providence, RI
Address correspondence to T. Tredennick (Tara_Tredennick{at}brown.edu)
Objective: To determine the reasons for cancellation of MR-guided breast biopsies and compare patient characteristics and MRI findings of those who underwent MR-guided biopsy to those that were cancelled.
Materials and Methods: 54 patients with 64 suspicious enhancing lesions were scheduled for an MR-guided biopsy at our institution between January 2004 and June 2006. Patient characteristics reviewed included the indication for the MRI, hormonal status of the patient, and age of the patient. MRI findings recorded included background enhancement and the size, morphology, and enhancement kinetics of the suspicious lesions. Surgical pathology of biopsied cases and imaging follow-up of cancelled cases were also recorded.
Results: Of the 64 lesions, 33% (n = 21) were cancelled with the remainder biopsied (n = 43). Reasons for cancellation included: lesion no longer visible (n = 11, 52%), reassessed as benign parenchymal enhancement (n = 7, 33%), or inaccessible (too posterior) (n = 3, 14%). There was a statistically significant difference in patient age (p = 0.05) and background enhancement (p = 0.05) in biopsied versus cancelled cases. Eight of the cancelled patients had follow-up imaging or biopsy and all had benign findings on follow-up studies. 23% of the 43 biopsied lesions were malignant.
Conclusion: Our results show that younger patients and patients with moderate or marked background enhancement are more likely to have MR-guided breast biopsy cancelled. As in prior studies, cancellation is usually due to lesion not being visualized or being reassessed as benign parenchymal enhancement. Awareness of which patients are most likely to have nonvisualization of enhancing lesions at biopsy may help guide the radiologist in determining which patients to recommend for biopsy and which to recommend short interval follow-up.
108. Usefulness of Image-Guided Core Breast Biopsy to Evaluate Response in Neoadjuvant Chemotherapy
Pai D.*; Roubidoux M.; Schott A.; Helvie M.; Tarolli J. University of Michigan, Ann Arbor, MI
Address correspondence to D. Pai (dpai{at}med.umich.edu)
Objective: Response to neoadjuvant chemotherapy is often evaluated using imaging methods to assess whether complete response occurs. All imaging methods have been previously reported to have false-negative and false-positive results. Our purpose was to determine the usefulness of image-guided core biopsy to assess response rather than imaging methods in breast cancer patients after neoadjuvant chemotherapy treatment.
Materials and Methods: Twenty-six women who presented to the University of Michigan Breast Care Center with stage IIA or IIB breast carcinoma, received 4 cycles of docetaxel and capecitabine neoadjuvant chemotherapy over a 16-week period. After completion of neoadjuvant chemotherapy, patients underwent either ultrasound and/or mammographically guided core biopsy of the presumed tumor, with site of biopsy directed at either the visualized residual mass or guided by radiopaque metallic marker that had been placed initially at time of diagnostic core biopsy. Patients with no tumor at the core biopsy underwent excisional biopsy, and those with residual tumor were given four cycles of doxorubicin and cyclophosphamide (AC). The pathology of the postneoadjuvant chemotherapy core biopsy and the excisional biopsy were compared. Pathologic complete response was defined as no residual invasive cancer.
Results: 21/26 (80.1%) patients had postneoadjuvant chemotherapy core biopsies which were positive for residual invasive tumor. Of the remaining 5 patients with negative core biopsies, all underwent surgical excision. Two patients (7.7%) were true negatives and 3 (11.5%) were false negatives. The specificity for detecting residual cancer was inferred as = 100%, sensitivity = 87.5%, negative predictive value = 40%. Etiologies for false negatives for residual cancer may relate to extensive fibrocystic parenchyma and therapy-related changes found on histology, sampling errors, absence of radiopaque biopsy markers for post chemotherapy core biopsy, or minimal residual disease. These factors are being analyzed.
Conclusion: Image-guided core biopsy to assess tumor response after neoadjuvant chemotherapy can be used to guide oncologic treatment, because it is a definitive and cost-effective indicator to detect residual tumor. Falsely negative biopsies may relate to fibrocystic and therapy-related changes or absence of radiopaque metallic marker during time of post chemotherapy core biopsy. Image-guided core biopsy reveals the patient subset of potential complete responders, in whom imaging methods could be useful.
109. Predictability of Co-Existing Malignancy with Intraductal Papilloma Obtained on Core Needle Biopsy: A Retrospective Review
Hermann G.1*; Mester J.1; Jaffer S.1; Bleiweiss I.1; Feig S.2 1. Mount Sinai Medical Center, New York, NY; 2. University of California-Irvine, Irvine, CA
Address correspondence to G. Hermann (george.hermann{at}mountsinai.org)
Objective: To evaluate the imaging patterns of intraductal papilloma (IP) obtained on pre-operative core needle biopsy (CNB) in order to predict the likelihood of co-existing malignancy at surgery.
Materials and Methods: 1733 consecutive image-guided percutaneous biopsies using either stereotactic or ultrasound guidance were performed between 03/01/2002–03/23/2006. All patients in whom CNB yielded IP were referred for surgery. Images were available for review in 61 cases of CNB-proven IP. CNB was performed in 27 masses and 34 calcifications. In each case we reviewed the pre-CNB images by recording the size, number and morphology of calcifications on mammography, and the size and borders of masses using the ACR BI-RADS lexicon system. Images were marked as benign or malignant based on the imaging patterns and without the knowledge of the surgical pathology. The radiologic findings were then compared with the final histologic result.
Results: At surgery, 14/61 (23%) cases of CBN-proven IP were upgraded to DCIS, including 11 masses and 3 calcifications. 47/61 (77%) remained benign at surgery, including 23 masses and 24 calcifications. Mean mass size was 19.3 mm in the malignant cases and 12.7 mm in the benign cases (p < 0.05). Mean calcification size was 27.3 mm in the malignant cases and 6.1 mm in the benign cases (p > 0.05). Following review of the pre-biopsy radiologic images, we correctly predicted co-existing malignancy in 8/11 (73%) malignant masses and 3/3 (100%) malignant calcifications. Co-existing malignancy was missed in 3/11 (27%) malignant masses. The presence of co-existing malignancy was correctly predicted in 10/23 (43%) benign masses and 10/24 (42%) benign calcifications. In our series, sensitivity = 79% and specificity = 57%.
Conclusion: While co-existing malignancy was correctly predicted in 73% of cases of CNB-proven IP where the imaging findings were suspicious, malignancy was underestimated in 27%. Surgical excision should be therefore recommended in all cases of IP diagnosed at CNB.
110. Does Sonographically Guided Clip Placement Facilitate Confirmation of Removal of Mammographically Occult Lesions After Localization?
Mercado C. L.*; Guth A. A.; Axelrod D.; Moy L.; Toth H. K.; Cangiarella J. NYU School of Medicine, New York, NY
Address correspondence to C. Mercado (cecilia.mercado{at}med.nyu.edu)
Objective: Confirmation of surgical removal of breast lesions not visualized on mammogram can sometimes be difficult with specimen radiography. We evaluated the benefit of placing a clip under sonographic guidance at the time of localization to aid in identifying mammographically occult lesions within the specimen at the time of surgical excision.
Materials and Methods: We reviewed 628 consecutive needle localizations, of which 157 sonographically guided procedures performed on mammographically occult lesions were identified. Needle localizations where a localizing clip was placed under sonographic guidance at the time of the localization procedure were identified and reviewed. The imaging during the localization procedure and clip placement (CP), the specimen radiographs and the histopathologic findings were reviewed.
Results: Of the 157 mammographically occult lesions, localizing clips were placed in 59 cases (1 case was excluded due to the lack of specimen radiographs for review), 77 were localized without CP and 21 were excluded due to the presence of a clip placed during previous percutaneous biopsy. The 58 localizations with CP were for masses with a mean lesion size of 9 mm. Postprocedure mammogram of all cases demonstrated appropriate clip deployment in the specific quadrant of the breast. Specimen radiography of localizations with CP demonstrated a clip within the specimen in 56 cases (97%) and visualization of the lesion in only 7 cases (12%). In the 2 cases (3%) where a clip was not identified in the specimen, follow-up mammography failed to demonstrate the clips within the breast, confirming clip removal during the surgical procedure. Specimen radiography of localizations without CP demonstrated visualization of the lesion in 18 (23%). Of the lesions localized with CP, 47 (81%) were benign and 11 (19%) were malignant. Of the 11 malignant lesions, none had a positive inked margin but 5 (46%) had close margins requiring re-excision. Of the lesions localized without CP, 51 (66%) were benign and 26 (34%) were malignant. Of the 26 malignant lesions, 2 (8%) had a positive inked margin and 8 (31%) had close margins requiring re-excision.
Conclusion: CP under sonographic guidance at time of needle localization is beneficial by providing immediate confirmation of accurate surgical removal of the localized lesion at the time of surgical excision. However, CP does not provide any reduction in the percentage of cases with close margins requiring re-excision.
111. Sonographically Guided Metallic Clip Placement at Time of Wire Localization for Subtle or Occult Mammographic Lesions: A Method to Verify Lesion Retrieval
Patterson S. K.*; Joe A.; Helvie M. A. University of Michigan Medical Center, Ann Arbor, MI
Address correspondence to S. Patterson (spatters{at}umich.edu)
Objective: To report the results of deploying a metallic marker using sonographic guidance to mark mammographically occult or subtle lesions immediately prior to wire localization for excisional biopsy. Because of the nature of these lesions, particularly intraductal and complex cystic masses, confirmation of retrieval on specimen radiography or sonography can be otherwise problematic.
Materials and Methods: IRB approval was obtained. We retrospectively reviewed the clinical, radiographic, and pathologic records of 21 patients with 24 lesions between 21 and 77 years old who underwent excisional biopsy with wire localization following sonographically guided marker placement with the UltraCLIP® II, between March 1, 2005 and May 31, 2006. After the marker was deployed, a wire localization needle was placed using sonographic guidance within the lesion or adjacent to it. For all procedures, a postprocedure wire localization mammogram was performed, confirming placement of the wire adjacent to the marker. The procedure mammogram, ultrasound, specimen radiographs and, specimen ultrasound images were reviewed and evaluated for the presence of the metallic marker, lesion or both. 46% of lesions were intraductal or complex cystic masses by ultrasound. Pathology of all specimens was recorded, and reviewed for concordance.
Results: Lesions ranged in size from 3 mm to 17 mm in maximum diameter, with an average size of 8 mm. 16 lesions (16/24–67%) were not apparent on specimen radiographs, 2 (2/24–8%) were vaguely apparent on specimen radiographs, 6 (6/24–25%) were apparent on specimen radiographs. No intraductal or complex cystic lesions were seen on specimen radiographs. 5 specimen sonograms were evaluated. Of those, 3 lesions (3/5-60%) were "suggested" sonographically in the specimens, but could not be completely confirmed. 2 (2/5-40%) were not seen. There were 3 cancers (13%), and remaining lesions were benign. All cancers were apparent on specimen radiographs. 22 (22/24–92%) of the markers were visualized on specimen radiographs. All pathology was concordant with imaging findings.
Conclusion: Given the high rate of marker visibility on specimen radiography and pathologic concordance, this method is an efficient way to mark mammographically occult or subtle lesions and verify lesion retrieval, particularly for intraductal or complex cystic lesions.
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