Local recurrence of breast cancer after skin-sparing mastectomy following core needle biopsy: case reports and review of the literature

The latest advances in diagnostic and therapeutic procedures for breast cancer have provided valuable technological breakthroughs. Yet the long-term consequences of these modern methods are still quite unclear. Such is the case for stereotactic or ultrasound-guided histologic needle biopsy and skin-sparing mastectomy. We report on three patients who presented with multicentric breast cancer diagnosed by stereotactic needle biopsy and treated by skin-sparing mastectomy. All three patients developed recurrence at the core needle entry site. Records of 58 patients with breast cancer who were treated by skin-sparing mastectomy followed by immediate reconstruction (with transverse rectus abdominis muscle [TRAM] flap or tissue expander) at the Breast Diseases Division of Buenos Aires British Hospital between December 1999 and December 2003 were reviewed retrospectively. Eleven of these patients were diagnosed by histologic needle biopsy. The mean follow-up was 28 months (range 5-60 months). Three (skin or subcutaneous) local recurrences at the needle entry site, diagnosed in a mean time of 23.6 months (16, 22, and 23 months), were reported. The three patients underwent complete resection with clear margins, radiation therapy to the "neobreast," and tamoxifen. All three patients are disease free with a mean postrecurrence follow-up of 24.3 months (30, 23, and 22 months). Based on the evidence of displacement of tumor cells and the potential nonresection of such tumor seeding at the time of skin-sparing mastectomy, as well as the poor probability of postoperative radiation therapy, we recommend surgical resection of the needle biopsy tract, including the dermal entry site, at the time of mastectomy.     

A case report of pseudoaneurysm after a core needle biopsy of breast cancer

Breast pseudoaneurysms after a core needle biopsy are a rare complication with a low incidence. However, it is important to be aware of the possibility of complications that require treatment.     

Drill needle biopsy for breast cancer

From 1977 to 1983 we have used electric drill needle biopsy of suspicious masses in the breast in 437 patients. In 104 patients with primary breast carcinoma 94 were diagnosed correctly by the initial biopsy, 9 were found on the second or third biopsy and one on the subsequent excisional biopsy. The rate of accuracy of the initial biopsy was 90.4 per cent. The diameters of the 104 carcinomas were less than 2 cm in 62 (59.6 per cent), 2–5 cm in 39 (37.5 per cent) and 5 cm or more in 3 (2.9 per cent). There were 17 patients (16.3 per cent) with a tumor 10 mm or less in diameter. Three hundred and thirty three patients had benign lesions. This drill needle biopsy method can be performed easily and accurately on nodules less than 2 cm, or even 10 mm or less nodules. For a diagnosis of early breast carcinoma made in the outpatient clinic or in screening examination programs, this method may be the most appropriate.     

Ductal carcinoma in situ and atypical ductal hyperplasia of the breast diagnosed at stereotactic core biopsy

Abstract: Stereotactic core needle biopsy (SCNB) allows specific histopathologic diagnoses to be made without surgery and has been demonstrated to be an accurate, cost-effective method of diagnosing breast disease, particularly nonpalpable lesions. However, recent studies have concluded that the diagnosis of atypical ductal hyperplasia (ADH) by means of SCNB has resulted in nearly equal odds that a coexisting malignant lesion will be missed. Furthermore, others have concluded that SCNB diagnosed as DCIS cannot reliably indicate the absence of tumor invasion in surgical excision. Between 1993 and 1998, 1,221 consecutive SCNB of mammographically identified lesions were performed using a 14-gauge automated device with an average of 5.3 cores obtained per lesion. ADH was identified in 19 (1.6%) lesions and DCIS in 89 (7.3%). Surgical biopsy was performed in 89 of these patients and histopathologic results from SCNB and surgical biopsies were reviewed and correlated. In 12 cases of ADH diagnosed by SCNB, surgical biopsy showed ADH in 8 (67%) cases and DCIS in the other 4 (33%) cases. In 77 cases of DCIS diagnosed by SCNB, a surgical biopsy showed DCIS in 55 (71%) cases, 6 more cases (8%) had DCIS with focal microinvasion, and 15 (19%) had invasive ductal carcinoma. In one case no residual tumor was found at surgery. In the author's patient population, the diagnosis of ADH at SCNB indicates high probability of DCIS or residual ADH in the surgical biopsy. The diagnosis of DCIS at SCNB is confirmed in the majority of surgical biopsies; however, a significant number of cases may show microinvasion or invasive carcinoma.     

Review of 125 SiteSelect stereotactic large-core breast biopsy procedures

Advances in stereotactic breast biopsies have introduced a variety of devices that yield different sizes of tissue samples. The choice of biopsy device should be based on which technique is most likely to yield a definitive diagnosis at the time of the initial biopsy. This is a prospective study of 104 patients who underwent a total of 125 stereotactic breast biopsies using the SiteSelect large-core biopsy device. From May 1999 to June 2001, 104 patients underwent 125 stereotactic breast biopsies with the SiteSelect large-core biopsy device. One hundred four 15 mm SiteSelect biopsies, eighteen 10 mm SiteSelect biopsies, and three 22 mm SiteSelect biopsies were performed. Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were found in 15% of the biopsies and infiltrating cancer was found in another 15% of the biopsies. Seventy-eight percent of the ADH and 90% of the DCIS lesions were associated with indeterminate calcifications noted on mammogram. Two of the 22 mm SiteSelect excisions yielded a specimen that contained the entire cancer with clear surgical margins. All of the patients with DCIS or invasive carcinoma underwent definitive surgical and adjuvant therapy. The sensitivity and specificity of SiteSelect in this series of patients was 100%. The SiteSelect biopsy procedure is safe, well tolerated by patients, and can be performed under local anesthesia. SiteSelect is comparable to an open excisional biopsy in its ability to obtain adequate tissue for accurate diagnosis, but excises significantly less normal surrounding breast tissue. Based on the data, indications for primary use of SiteSelect are indeterminate calcifications on mammogram, rebiopsy of a vacuum-assisted biopsy site that yielded atypia on pathologic examination, and complete excision of a lesion suspicious for invasive carcinoma in order to assess actual size and margin status.     

Osseous metaplasia of the breast: diagnosis with stereotactic core biopsy

There are approximately 200 reported cases of breast tumors containing areas of bone. The majority of the neoplasms are sarcomas, phylloides tumors, or fibroadenomata. We present a case of osseous metaplasia mammographically detected by clustered heterogeneous calcifications. Stereotactic core biopsy revealed the presence of well-formed bone tissue without associated neolplasia. The case represents the first reported case of mammographically detected osseous metaplasia confirmed by core biopsy.     

Risk of needle-track seeding after diagnostic image-guided core needle biopsy in breast cancer.

OBJECTIVE: Image-guided core needle biopsy (IGCNB) is an accepted technique for sampling nonpalpable mammographically detected suspicious breast lesions. However, the concern for needle-track seeding in malignant lesions remains. An alternative to IGCNB is needle-localization breast biopsy (NLBB). No study has been done to compare the local recurrence rate of breast cancer after IGCNB versus NLBB. METHODS: We have retrospectively reviewed the local recurrence of breast cancer in patients diagnosed by either IGCNB or NLBB who underwent breast-preserving treatment for their cancer between May 1990 and June 1995. The length of follow-up averaged 29.7 months. RESULTS: Three hundred ninety-eight patients were diagnosed with breast cancer by IGCNB (297 patients) or NLBB (101 patients). All patients underwent breast-conserving surgery. Fifteen (3.77%) patients had a local recurrence: 11(3.70%) in the IGCNB group and 4 (3.96%) in the NLBB group. These recurrence rates are not statistically different. CONCLUSION: Concerns for seeding of the needle track with cancer cells have made some surgeons wary of IGCNB. However, we did not find an increased rate of recurrence due to needle-track seeding, and IGCNB remains our procedure of choice for diagnosing mammographically detected suspicious breast lesions.     

超声联合空芯针穿刺活检在原发性乳腺癌腋窝淋巴结转移中的诊断价值

目的研究术前超声引导下淋巴结空芯针穿刺(US-CNB)在检测乳腺癌患者腋窝淋巴结转移中的诊断价值。方法回顾性研究2016年1月至2017年7月在我院行超声检查及超声引导下空芯针穿刺活检,并有腋窝淋巴结术后病理诊断的所有乳腺癌病人。计算US-CNB的敏感性、特异性、阳性预测值(PPV)、阴性预测值(NPV)、准确性,同时统计Kappa值以明确一致性情况。分析US-CNB结果与N和T分期的关系。结果以术后病理结果为金标准,US-CNB诊断淋巴结转移的敏感性为91.8%(90/98),特异性为58.3%(21/36),PPV为85.7%(90/105),NPV为72.4%(21/29),误诊率为41.7%(15/36),漏诊率为8.2%(8/98),约登指数为50.1%,准确性82.8%(111/134),ROC曲线下面积为0.751。比较US-CNB与术后病理的一致性,Kappa=0.535。排除新辅助化疗患者14例,特异性、PPV和误诊率分别为95.5%(21/22)、98.9%(90/91)以及4.5%,约登指数87.3%,准确性92.5%(111/120),ROC曲线下面积为0.936(P0.0001),比较排除后US-CNB与术后病理的一致性,Kappa=0.777。随着T和N分期的增加,US-CNB的敏感性增加。结论乳腺癌患者术前腋窝淋巴结空芯针穿刺可作为诊断腋窝淋巴结转移的可靠方法,与术后病理有较高的一致性。淋巴结穿刺结果阳性可能与乳腺癌较高肿瘤负荷相关。     

Comparison of histologic diagnosis between stereotactic core needle biopsy and open surgical biopsy

Background: This study correlates the histologic findings of stereotactic core needle biopsy (SCNB) with open surgical biopsy (OSB) and identifies which lesions can be treated definitively based only on the SCNB histology. Methods: Women who underwent SCNB between July 1, 1993, and January 1, 1969, were identified by retrospective chart review. Mammographic (MGM) lesions found by SCNB to be ductal or lobular hyperplasia with atypia, or carcinoma underwent OSB. When the histologic findings by SCNB were inconsistent with the MGM findings, the lesion also underwent OSB. Results: 799 women underwent SCNB with 96 (12%) of these going on to OSB. MGM findings in the 92 who presented without a palpable mass included microcalcifications (MCS) in 39, mass in 47, MCS and mass in 7, and tissue distortion in 3. One hundred one breast lesions biopsied first by SCNB, then by OSB were correlated histologically. Sensitivity of SCNB is 89%, with a specificity of 94%. Eight-four women (88%) were able to have definitive treatment at time of OSB because of prior SCNB, and 703/799 (88%) of women were spared OSB entirely. Conclusion: SCNB accurately identifies benign breast histology and invasive cancers in women with MGM abnormalities, a distinct advantage over fine needle aspiration cytology. SCNB does not reliably identify women with DCIS and invasion. All women with SCNB diagnosis of ductal or lobular atypia should also undergo OSB.     

A novel way of hook wire placement for surgical resection of suspicious breast lesions using the stereotactic vacuum assisted breast biopsy table

Preoperative hook localization is a necessary procedure for targeting impalpable breast lesions. The aim of the current study is to introduce an alternative technique of wire placement by using the stereotactic biopsy device instead of the conventionally used mammography device. Fifty-one patients with impalpable mammographic lesions, graded BIRADS 4 or 5, were prospectively enrolled. Mean duration was 7 ± 1.5 minutes. Lesion-to-wire distance was <1 cm in 96% (51/53). Hook wire placement using the stereotactic biopsy device is considered as a safe, accurate, fast, and well-tolerable for the patient procedure.     

Papillary lesions of the breast diagnosed by core needle biopsy: 71 cases with surgical follow-up

Background

Papillary breast lesions comprise a spectrum of histopathologic diagnoses ranging from benign papillomas to papillary carcinomas. There is ongoing controversy regarding the management of papillary lesions diagnosed by core needle biopsy (CNB). Some authors advocate observation of papillary lesions when the CNB is benign, while others recommend surgical excision of all papillary lesions. The current study assessed the adequacy of CNB in evaluating papillary breast lesions.

Methods

A search of the pathology database at our institution identified 122 papillary lesions diagnosed by CNB. The study population consisted of 71 papillary lesions that were subsequently surgically excised.

Results

Of the 71 papillary lesions excised, 8 were malignant, 16 were atypical, and 47 were benign at the time of CNB. Of the 47 papillary lesions thought to be benign, 13 (28%) revealed atypia and 4 (9%) revealed malignancy upon surgical excision. Of the 13 atypical papillary lesions on CNB, 7 lesions (54%) were associated with malignancy upon excision. Slightly over half the upgrades were due to finding atypia or malignancy in the tissue surrounding the papillary lesion. The total rate of upgrades from the CNB diagnosis to the excisional diagnosis was 38%.

Conclusions

When a core biopsy of a papillary lesion is encountered, there is a strong likelihood of discovering atypia or malignancy in the index lesion or in close proximity. Therefore, surgical excision should be performed to avoid missing a malignancy and to allow for accurate breast cancer risk assessment that can impact survival and decisions regarding chemoprevention.     

Milk of calcium in the breast: appearance on prone stereotactic imaging

Abstract: Microcalcifications discovered by mammography require careful analysis, occasionally leading to core biopsy to exclude associated breast cancer. We report unrecognized milk of calcium layering on small field of view prone digital stereotactic images. We illustrate important features on prone digital images attributed to milk of calcium which can exclude breast neoplasm, suggest this diagnosis, and prevent unnecessary biopsy.     

Distinguishing papillary endothelial hyperplasia and angiosarcoma on core needle biopsy of the breast: The importance of clinical and radiologic correlation

Papillary endothelial hyperplasia (PEH) is a rare non‐neoplastic exuberant organizing hematoma that can closely mimic angiosarcoma due to a resemblance to malignant anastomosing blood vessels. It could be particularly difficult to distinguish PEH from angiosarcoma in breast core needle biopsies. We identified all cases of these lesions diagnosed on core needle biopsy in order to identify clinical, radiologic, and pathologic features that could prove helpful to arrive at the correct diagnosis. Four cases of PEH and 4 cases of angiosarcoma were identified. The mean age at diagnosis was 62 for PEH and 33 for primary angiosarcoma. All cases of PEH formed small masses with circumscribed or lobulated margins by imaging (mean size 0.9 cm). In 3 cases, the masses were difficult or impossible to identify after the biopsy. Angiosarcomas presented as larger masses with ill‐defined margins (mean size 2.8 cm) that were unchanged in size after biopsy. PEH was surrounded by adipose tissue, whereas angiosarcoma invaded into fibrous stroma and involved lobules. The pseudopapillary structures of PEH were composed mainly of collagen, and thus, additional histologic stains for fibrin were not helpful for diagnosis. The 4 patients with PEH received no further treatment and are alive and disease‐free at 2‐11 years of follow‐up. In contrast, the patients with angiosarcoma underwent mastectomy and chemotherapy or radiation therapy. Two of the patients with angiosarcoma died 3 years after diagnosis and the other 2 patients are alive without disease at 5 and 6 years. Therefore, distinguishing PEH and angiosarcoma is essential for appropriate management. This is the first series to compare these lesions on core needle biopsy and the first to note important clinical, imaging, and histologic differences that aid in making a diagnosis of PEH with confidence on breast core needle biopsy.     

Stereotactic core needle biopsy of mammographic breast lesions as a viable alternative to surgical biopsy

Background: Stereotactic needle biopsy technique has received considerable attention as a possible alternative to surgical biopsy of nonpalpable breast lesions. The exact role of this procedure in the management of mammographic breast lesions has not yet been accurately defined. Methods: Data have been collected prospectively on 416 patients over an 8-month period (January 1992 through August 1992). Of 416, 356 patients underwent only stereotactic breast biopsy with a 14-gauge needle. Sixty patients underwent stereotactic breast biopsy followed by surgical biopsy. Based on mammographic findings before biopsy, lesions were classified as benign (24%), likely benign (49%), malignant (2%), likely malignant (6%), and indeterminate (19%). The number of core biopsy specimens obtained from each patient ranged from one to six. Results: The specimen was considered adequate in 98% of cases. Complications were minimal. The tissue diagnosis was benign in 92% and malignant in 8% of patients. In those patients undergoing surgical and stereotactic biopsy, 57 of 60 had matching histopathological results, representing an agreement rate of 95% (p<0.001). The three patients whose histopathological results did not match had malignant diagnoses on stereotactic biopsy that were subsequently not identified in the modified radical mastectomy specimen because the entire focus of malignancy was removed by the several passes made by the core needle during biopsy. No patient had a negative stereotactic biopsy result in whom malignancy was later detected by surgical biopsy. Conclusions: This study indicates excellent agreement between surgical and stereotactic needle biopsy findings. Stereotactic biopsy with a 14-gauge needle could obviate the need for surgical biopsy in certain women with radiologically benign, likely benign, and indeterminate lesions. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Bilateral orbital metastases from breast cancer: a case report of successful palliation using stereotactic radiotherapy

Of ophthalmic involvement from metastatic breast cancer, extraocular/intraorbital metastases are extremely rare. External beam radiotherapy has been a mainstay palliation for symptomatic orbital metastases. We present a case of bilateral orbital metastases from breast cancer successfully treated with stereotactic radiotherapy (SRT). A 38-year-old woman presented with decreased vision in the right eye for 3 weeks. Eight months previously, she underwent whole-brain radiotherapy for multiple brain metastases from breast cancer. Visual acuity was hand motion, and the eyelid closed incompletely in the affected eye. Computed tomography scans showed a 3-cm extraconal mass in the right orbit. She underwent temporary tarsorrhaphy followed by SRT. A total dose of 39 Gy was delivered to the right orbital mass in three daily fractions. Four months later, her visual function was normal in both eyes and the right orbital mass disappeared. A new lesion was detected in the left orbit. She underwent SRT for the left orbital lesion using the same dose-fractionation schedule. No radiation-related toxicities were observed. She died 19 months after the first SRT. Our case suggests that SRT may be an effective and safe treatment option in patients with orbital metastases from breast cancer.     

How image‐guided core needle biopsies altered the treatment of breast disease: Challenges accepted and opportunities taken

The technique of combining stereotactic targeting of breast lesions with an automated spring‐loaded needle biopsy gun reported in 1990 by Steve Parker and colleagues not only ushered in the era of diagnosis almost exclusively by image guided core needle biopsy, but also profoundly changed the practice of pathologists, radiologists, surgeons, and medical oncologists and had major effects on the treatment of women with breast cancer. In this special issue of The Breast Journal celebrating 25 years of publication, it is of value to reflect back on these changes, some expected and some unanticipated, which have occurred over the past three decades and to consider the reasons why core needle biopsies should be considered a milestone in breast pathology.     

A comparative analysis of core needle biopsy and final excision for breast cancer: histology and marker expression

Background

Core needle biopsy (CNB) is used increasingly not only to diagnose breast cancer, but to determine tumor histology, grade and marker expression, select neoadjuvant therapy, and predict sentinel lymph node status. Thus, we undertook this study to evaluate the accuracy of CNB as a predictor of breast cancer histology and marker expression.

Methods

We identified 209 Breast Cancer Registry cases with a preoperative CNB and reviewed all clinicopathologic data for accuracy. Statistical analysis was performed with statistical software.

Results

CNB unequivocally showed cancer in 93%. Exact tumor histology concordance was 86%. Ductal carcinoma in situ on CNB was upgraded to invasive cancer in 23%. Concordance was substantial for estrogen receptor expression (88%, κ = .71), but kappa values were less than .6 for tumor grade, mitotic rate, progesterone receptor (PR), Ki-67, HER-2/neu, and p53 expression.

Conclusions

Reliance on CNB grade and marker expression for critical decision making may be inadvisable. Further study is warranted to optimize breast cancer patient care.     

A sensitivity and specificity comparison of fine needle aspiration cytology and core needle biopsy in evaluation of suspicious breast lesions: A systematic review and meta-analysis

PurposeBreast cancer detections for women with suspicious lesions mainly depend on two non-operative pathological tests-fine needle aspiration cytology (FNAC) and core needle biopsy (CNB). The aim of this systematic review was to compare the sensitivity and specificity of CNB and FNAC in this setting.MethodsThe data sources included MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials (CENTRAL) till February 2016. We included prospective series of studies which directly compared the accuracy of FNAC and CNB. We used forest plots to display the sensitivity and specificity of FNAC and CNB respectively. Pre-specified subgroup analyses and sensitivity analysis were conducted.ResultsUltimately, 12 articles (1802 patients) were included in the final analysis. The pooled analysis shows that the sensitivity of CNB is better than that of FNAC [87% (95% CI, 84%–88%, I² = 88.5%) versus 74% (95% CI, 72%–77%, I² = 88.3%)] and the specificity of CNB is similar to that of FNAC [98% (95% CI, 96%–99%, I² = 76.2%) versus 96% (95% CI, 94%–98%, I² = 39.0%)]. For subgroup analysis, the sensitivities of both tests are better for palpable lesions than that of non-palpable lesions. Sensitivity analysis shows the robustness of the primary analysis.ConclusionOur study suggests that both of FNAC and CNB have good clinical performance. In similar circumstances, the sensitivity of CNB is better than that of FNAC, while their specificities are similar. FNAC could be still considered the first choice to evaluate suspicious nonpalpable breast lesions.     

Imaging and management of fibroepithelial breast lesions on percutaneous core needle biopsy

The purpose of this study is to review the clinical presentation, multi‐modality appearance, and management of the most common benign and malignant fibroepithelial lesions of the breast. Fibroepithelial lesions of the breast may exhibit characteristic features on mammography, ultrasound, and MRI, although definitive diagnosis most often requires biopsy and at times, surgical excision. Knowledge of the imaging features can assist in refining the differential diagnosis and guiding appropriate management.