110110 B9 Breast Biopsy Presentation for RSNA
Breast Cancer Yield after Short Interval Follow-up Compared to Return to Routine Annual Screen in Patients with Benign Stereotactic or Ultrasound-guided Biopsy Results
Content
Breast
Cancer
Yield
a/er
Short-‐ Interval
Follow-‐Up
Compared
to
Return
to
Rou=ne
Annual
Screen
in
Pa=ents
with
Benign
Stereotac=c
or
Ultrasound
Guided
Biopsy
Results
JM
Johnson,
MD;
AK
Johnson,
MD;
ES
O'Meara,
PhD;
D
Migliore8,
PhD;
BM
Geller,
EdD;
P
Frawley,
SD
Herschorn,
MD;
EN
Hotaling,
MD
RSNA 96th Scientific Assembly & Annual Meeting, November 28 – December 3, Chicago, IL.
Disclosures
• No
contributors
have
any
relevant
disclosures.
Background
• Biopsy
of
breast
lesions
is
increasingly
being
performed
using
ultrasound
and
stereotacKc
guidance.
• Exact
#
of
percutaneous
breast
biopsies
performed
annually
in
the
US
is
unknown,
esKmates
range
500,000
-‐
1,000,000.
• #
of
percutaneous
breast
biopsies
performed
in
the
US
conKnues
to
increase;
only
20
-‐
33%
of
these
biopsy
samples
prove
to
be
cancer.
Accuracy
• Percutaneous
breast
biopsy
has
been
shown
to
be
a
highly
accurate
procedure.
• With
stereotac=c
biopsies,
reports
of
false-‐ negaKve
rates
range
from
2.9
–7.8%.
• With
ultrasound
guided
core
needle
biopsy,
reports
of
false-‐negaKve
rates
range
from
0
-‐
1.7%.
Concordance
• ConfirmaKon
of
lesion
retrieval
aYer
biopsy
is
essenKal
and
can
be
confirmed
by
specimen
radiography,
post
biopsy
mammography
and
by
correlaKon
of
histologic
findings
with
imaging
characterisKcs.
• Imaging–histologic
discordance
aYer
breast
biopsy
occurs
when
histologic
findings
do
not
provide
a
sufficient
explanaKon
for
imaging
features.
• Imaging–histologic
discordance
at
stereotacKc
or
ultrasound
guided
biopsy
is
an
indica=on
for
re-‐ biopsy.
Biopsy
Follow-‐Up
• Li^le
evidence
to
guide
how
to
follow-‐up
paKents
with
benign
biopsies.
• Many
centers
recommend
return
for
a
six-‐month
follow-‐up
unilateral
mammogram
or
ultrasound
to
ensure
that
there
has
been
no
change
at
the
biopsy
site.
• Other
centers
perform
a
four-‐month
follow-‐up
and
others
return
paKents
to
annual
screening.
Mo
Screening
≠
Mo
Be^er
• Using
conservaKve
esKmates,
as
many
as
330,000
women
annually
receive
a
breast
biopsy
with
benign
pathology
result.
• SIFU
leads
to
increase
healthcare
uKlizaKon
and
increased
paKent
anxiety.
• There
are
adverse
psychological
and
immunological
impacts
of
biopsy
that
persist
beyond
the
biopsy.
• The
effects
may
be
prolonged
with
the
addiKon
of
short-‐term
follow-‐up.
Purpose
• Our
goal
was
to
compare
the
cancer
detecKon
rate
and
nodal
status,
stage
and
tumor
size
following
a
benign
stereotacKc
or
ultrasound
guided
breast
biopsy
between
paKents
with
SIFU
and
RTAS.
DefiniKons
• SIFU
and
RTAS
defined
based
on
observed
Kme
since
biopsy,
not
just
radiologist
recommendaKon
or
indicaKon.
• "SIFU"
defined
as
(a)
imaging
3-‐9
months
aYer
biopsy
with
(b)
indicaKon
"rouKne
screening"
or
"short-‐interval
follow-‐up".
• "RTAS"
defined
as
(a)
imaging
9-‐18
months
aYer
biopsy
with
(b)
indicaKon
"rouKne
screening"
or
"short-‐interval
follow-‐up".
Rules
• Cases
with
findings
of
atypical
hyperplasia
or
lobular
carcinoma
in
situ
were
excluded.
• If
any
cancer
diagnosis
was
found
to
precede
the
benign
biopsy
or
occurred
within
the
following
90
days,
the
biopsy
was
excluded.
• We
required
3
months
of
follow-‐up
for
cancer
detecKon
at
post-‐biopsy
imaging.
• We
examined
biopsies
that
resulted
from
both
screening
and
diagnosKc
evaluaKons.
Rules
2
• Only
core
biopsies
with
ultrasound
or
stereotacKc
guidance
were
evaluated.
• Any
cases
in
which
there
was
a
repeat
biopsy
within
3
months
or
before
follow-‐up
imaging
were
excluded
due
to
the
likelihood
of
represenKng
discordant
radiology-‐pathology
results.
• Diagnosis
of
ipsilateral
invasive
cancer
or
DCIS
within
3
months
of
the
1st
follow-‐up
imaging
exam
and
tumor
characterisKcs
were
determined
through
linkage
with
pathology
databases
and
tumor
registries.
Methods
Results
• Total
of
19,598
benign
biopsies
among
18,367
women
were
idenKfied.
– Post-‐biopsy
imaging
• SIFU
7397
• RTAS
3604
• Other
8597
Demographics
SIFU
(N
=
7397)
CharacterisKc
Age
<40
40-‐49
50-‐59
60-‐69
70-‐79
≥80
Race/ethnicity
White,
non-‐hispanic
Black,
non-‐hispanic
Asian/Pacific
Islander
90.5
3.6
2
89
4.1
2.7
6
34
31.8
16.6
9.3
2.3
5.5
35.3
31.7
16
9
2.5
%
RTAS
(N
=
3604)
%
Demographics
SIFU
(N
=
7397)
RTAS
(N
=
3604)
CharacterisKc
BMI
(kg/m2)
<25
25
to
<30
30
to
<35
≥35
Current
HRT
Family
history
of
breast
cancer
No
breast
symptoms,
by
self-‐report
43
28.8
16.8
11.4
17.4
17.2
78
43.5
29
16.6
11
17.5
19.4
91.6
%
%
Demographics
SIFU
(N
=
7397)
RTAS
(N
=
3604)
CharacterisKc
Mammographic
(BI-‐RADS)
breast
density
Almost
enKrely
fat
Sca^ered
fibroglandular
densiKes
Heterogeneously
dense
Extremely
dense
Pre-‐biopsy
imaging
was
for
rou=ne
screening
4.8
38.8
49.2
7.2
76
%
-‐
4.7
35.9
50.2
9.3
77.6
%
-‐
Breast
Cancer
w/in
3
months
aYer
post-‐biopsy
imaging
SIFU
N
benign
biopsies
Incident
ipsilateral
breast
cancer
cases
diagnoses
w/in
3
months
a/er
post-‐biopsy
imaging,
N
7397
RTAS
3604
40
18
Rate
per
1000
imaging
exams
(95%
CI)
Invasive
cancer
(nonmissing),
N
Percent
(95%
CI)
5.4
(3.9,
7.4)
26
(40)
5.0
(3.0,
7.9)
12
(18)
65%
(48%,
79%)
67%
(41%,
87%)
Breast
Cancer
w/in
3
months
aYer
post-‐biopsy
imaging
SIFU
Among
invasive
cancers
Node
posi=ve
(non
missing),
N
Percent
(95%
CI)
Late
stage
(III
or
IV)
(non
missing),
N
Percent
(95%
CI)
Large
size
(≥20
mm)
(non
missing),
N
Percent
(95%
CI)
7
(23)
30%
(13%,
53%)
4
(22)
18%
(5%,
40%)
4
(22)
18%
(5%,
40%)
3
(10)
30%
(7%,
76%)
3
(10)
30%
(7%,
65%)
3
(11)
27%
(6%,
61%)
RTAS
Conclusion
• Our
results
do
not
show
a
staKsKcally
significant
difference
in
the
rate
of
ipsilateral
cancer
detecKon
between
SIFU
and
RTAS
following
a
benign
breast
biopsy.
• Rates
of
invasive
cancer
and
posiKve
nodal
status
also
did
not
achieve
staKsKcal
significance
between
the
groups.
Conclusion
2
• Having
a
benign
breast
biopsy
is
a
posiKve
risk
factor
for
breast
cancer
(Breast
Cancer
Risk
Assessment
Tool
and
Gail
Model).
• Despite
the
posiKve
relaKve
risk
factor
associated
with
a
biopsy,
the
ideal
method
of
follow-‐up
for
women
with
benign
concordant
breast
biopsies
has
not
been
studied.
• Our
results
suggest
that
the
pracKce
of
SIFU
following
a
benign
biopsy
may
not
offer
significant
advantage
over
RTAS
considering
the
cost
and
Kme
involved.
Strengths
• Large
sample
of
both
paKents
and
radiologists
which
is
representaKve
of
diverse
US
pracKces.
• To
our
knowledge,
this
is
the
first
study
to
assess
the
outcome
differences
between
SIFU
and
RTAS
following
a
benign
concordant
breast
biopsy.
• PaKent,
radiologic,
and
cancer
data
within
the
BCSC
provides
an
opportunity
to
examine
follow-‐ up
outcomes
in
a
large
data
set
collected
in
a
common
format.
Weaknesses
• Small
#
of
cancers
detected
precludes
sub-‐groups
analysis
for
difference
in
outcome
between
groups
(i.e.,
older
versus
younger,
white
versus
non-‐white,
HRT
vs.
no
HRT,
etc.).
• RetrospecKve
nature
has
inherent
weaknesses
including
possibility
of
incorrectly
filed
data
and
missing
data
points.
• Predominance
of
White,
non-‐Hispanic
paKents
(~85%)
in
our
data
set
limits
generalizability
of
our
data
to
non-‐Whites.
Clinical
Relevance
• These
results
suggest
that
the
pracKce
of
SIFU
following
a
benign
biopsy
may
not
offer
significant
advantage
over
RTAS
considering
the
cost
and
Kme
involved.
References
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References
13.
Liberman
L,
Drotman
M,
Morris
EA,
et
al.
Imaging-‐histologic
discordance
at
percutaneous
breast
biopsy.
Cancer.
2000;89 (12):2538-‐46.
14.
Philpo^s
LE,
Hooley
RJ,
Lee
CH.
Comparison
of
automated
versus
vacuu m-‐assisted
biopsy
methods
for
sonographically
guided
core
biopsy
of
the
breast.
AJR
Am
J
Roentgenol.
2003;180(2):347-‐51.
15.
Parker
SH,
Klaus
AJ,
McWey
PJ,
et
al.
Sonographically
guided
direcKonal
vacuum-‐assisted
breast
biopsy
using
a
handheld
device.
AJR
Am
J
Roentgenol.
2001;177(2):405-‐8.
16.
Philpo^s
LE,
Shaheen
NA,
Carter
D,
Lange
RC,
Lee
CH.
Comparison
of
rebiopsy
rates
aYer
stereotacKc
core
needle
biopsy
of
the
breast
with
11-‐gauge
vacuum
sucKon
probe
versus
14-‐gauge
needle
and
automaKc
gun.
AJR
Am
J
Roentgenol.
1999;172 (3):683-‐7.
17.
Meyer
JE,
Smith
DN,
Lester
SC,
et
al.
Large-‐needle
core
biopsy:
nonmalignant
breast
abnormaliKes
evaluated
with
surgical
excision
or
repeat
core
biopsy.
Radiology.
1998;206(3):717-‐20.
18.
Liberman
L,
Dershaw
DD,
Glassman
JR,
et
al.
Analysis
of
cancers
not
diagnosed
at
stereotacKc
core
breast
biopsy.
Radiology.
1997;203(1):151-‐7.
19.
Gail
MH,
Brinton
LA,
Byar
DP,
et
al.
ProjecKng
individualized
probabiliKes
of
developing
breast
cancer
for
white
females
who
are
being
examined
annually.
J
Natl
Cancer
Inst.
1989;81(24):1879-‐86.
20.
Decarli
A,
Calza
S,
Masala
G,
Specchia
C,
Palli
D,
Gail
MH.
Gail
model
for
predicKon
of
absolute
risk
of
invasive
breast
cancer:
independent
evaluaKon
in
the
Florence-‐European
ProspecKve
InvesKgaKon
Into
Cancer
and
NutriKon
cohort.
J
Natl
Cancer
Inst.
2006;98(23):1686-‐93.
21.
Bre^
J,
Austoker
J,
Ong
G.
Do
women
who
undergo
further
invesKgaKon
for
breast
screening
suffer
adverse
psychological
consequences?
A
mulK-‐centre
follow-‐up
study
comparing
different
breast
screening
result
groups
five
months
aYer
their
last
breast
screening
appointment.
J
Public
Health
Med.
1998;20(4):396-‐403.
22.
Witek-‐Janusek
L,
Gabram
S,
Mathews
HL.
Psychologic
stress,
reduced
NK
cell
acKvity,
and
cytokine
dysregulaKon
in
women
experiencing
diagnosKc
breast
biopsy.
Psychoneuroendocrinology.
2007;32(1):22-‐35.
Cancer
Yield
a/er
Short-‐ Interval
Follow-‐Up
Compared
to
Return
to
Rou=ne
Annual
Screen
in
Pa=ents
with
Benign
Stereotac=c
or
Ultrasound
Guided
Biopsy
Results
JM
Johnson,
MD;
AK
Johnson,
MD;
ES
O'Meara,
PhD;
D
Migliore8,
PhD;
BM
Geller,
EdD;
P
Frawley,
SD
Herschorn,
MD;
EN
Hotaling,
MD
RSNA 96th Scientific Assembly & Annual Meeting, November 28 – December 3, Chicago, IL.
Disclosures
• No
contributors
have
any
relevant
disclosures.
Background
• Biopsy
of
breast
lesions
is
increasingly
being
performed
using
ultrasound
and
stereotacKc
guidance.
• Exact
#
of
percutaneous
breast
biopsies
performed
annually
in
the
US
is
unknown,
esKmates
range
500,000
-‐
1,000,000.
• #
of
percutaneous
breast
biopsies
performed
in
the
US
conKnues
to
increase;
only
20
-‐
33%
of
these
biopsy
samples
prove
to
be
cancer.
Accuracy
• Percutaneous
breast
biopsy
has
been
shown
to
be
a
highly
accurate
procedure.
• With
stereotac=c
biopsies,
reports
of
false-‐ negaKve
rates
range
from
2.9
–7.8%.
• With
ultrasound
guided
core
needle
biopsy,
reports
of
false-‐negaKve
rates
range
from
0
-‐
1.7%.
Concordance
• ConfirmaKon
of
lesion
retrieval
aYer
biopsy
is
essenKal
and
can
be
confirmed
by
specimen
radiography,
post
biopsy
mammography
and
by
correlaKon
of
histologic
findings
with
imaging
characterisKcs.
• Imaging–histologic
discordance
aYer
breast
biopsy
occurs
when
histologic
findings
do
not
provide
a
sufficient
explanaKon
for
imaging
features.
• Imaging–histologic
discordance
at
stereotacKc
or
ultrasound
guided
biopsy
is
an
indica=on
for
re-‐ biopsy.
Biopsy
Follow-‐Up
• Li^le
evidence
to
guide
how
to
follow-‐up
paKents
with
benign
biopsies.
• Many
centers
recommend
return
for
a
six-‐month
follow-‐up
unilateral
mammogram
or
ultrasound
to
ensure
that
there
has
been
no
change
at
the
biopsy
site.
• Other
centers
perform
a
four-‐month
follow-‐up
and
others
return
paKents
to
annual
screening.
Mo
Screening
≠
Mo
Be^er
• Using
conservaKve
esKmates,
as
many
as
330,000
women
annually
receive
a
breast
biopsy
with
benign
pathology
result.
• SIFU
leads
to
increase
healthcare
uKlizaKon
and
increased
paKent
anxiety.
• There
are
adverse
psychological
and
immunological
impacts
of
biopsy
that
persist
beyond
the
biopsy.
• The
effects
may
be
prolonged
with
the
addiKon
of
short-‐term
follow-‐up.
Purpose
• Our
goal
was
to
compare
the
cancer
detecKon
rate
and
nodal
status,
stage
and
tumor
size
following
a
benign
stereotacKc
or
ultrasound
guided
breast
biopsy
between
paKents
with
SIFU
and
RTAS.
DefiniKons
• SIFU
and
RTAS
defined
based
on
observed
Kme
since
biopsy,
not
just
radiologist
recommendaKon
or
indicaKon.
• "SIFU"
defined
as
(a)
imaging
3-‐9
months
aYer
biopsy
with
(b)
indicaKon
"rouKne
screening"
or
"short-‐interval
follow-‐up".
• "RTAS"
defined
as
(a)
imaging
9-‐18
months
aYer
biopsy
with
(b)
indicaKon
"rouKne
screening"
or
"short-‐interval
follow-‐up".
Rules
• Cases
with
findings
of
atypical
hyperplasia
or
lobular
carcinoma
in
situ
were
excluded.
• If
any
cancer
diagnosis
was
found
to
precede
the
benign
biopsy
or
occurred
within
the
following
90
days,
the
biopsy
was
excluded.
• We
required
3
months
of
follow-‐up
for
cancer
detecKon
at
post-‐biopsy
imaging.
• We
examined
biopsies
that
resulted
from
both
screening
and
diagnosKc
evaluaKons.
Rules
2
• Only
core
biopsies
with
ultrasound
or
stereotacKc
guidance
were
evaluated.
• Any
cases
in
which
there
was
a
repeat
biopsy
within
3
months
or
before
follow-‐up
imaging
were
excluded
due
to
the
likelihood
of
represenKng
discordant
radiology-‐pathology
results.
• Diagnosis
of
ipsilateral
invasive
cancer
or
DCIS
within
3
months
of
the
1st
follow-‐up
imaging
exam
and
tumor
characterisKcs
were
determined
through
linkage
with
pathology
databases
and
tumor
registries.
Methods
Results
• Total
of
19,598
benign
biopsies
among
18,367
women
were
idenKfied.
– Post-‐biopsy
imaging
• SIFU
7397
• RTAS
3604
• Other
8597
Demographics
SIFU
(N
=
7397)
CharacterisKc
Age
<40
40-‐49
50-‐59
60-‐69
70-‐79
≥80
Race/ethnicity
White,
non-‐hispanic
Black,
non-‐hispanic
Asian/Pacific
Islander
90.5
3.6
2
89
4.1
2.7
6
34
31.8
16.6
9.3
2.3
5.5
35.3
31.7
16
9
2.5
%
RTAS
(N
=
3604)
%
Demographics
SIFU
(N
=
7397)
RTAS
(N
=
3604)
CharacterisKc
BMI
(kg/m2)
<25
25
to
<30
30
to
<35
≥35
Current
HRT
Family
history
of
breast
cancer
No
breast
symptoms,
by
self-‐report
43
28.8
16.8
11.4
17.4
17.2
78
43.5
29
16.6
11
17.5
19.4
91.6
%
%
Demographics
SIFU
(N
=
7397)
RTAS
(N
=
3604)
CharacterisKc
Mammographic
(BI-‐RADS)
breast
density
Almost
enKrely
fat
Sca^ered
fibroglandular
densiKes
Heterogeneously
dense
Extremely
dense
Pre-‐biopsy
imaging
was
for
rou=ne
screening
4.8
38.8
49.2
7.2
76
%
-‐
4.7
35.9
50.2
9.3
77.6
%
-‐
Breast
Cancer
w/in
3
months
aYer
post-‐biopsy
imaging
SIFU
N
benign
biopsies
Incident
ipsilateral
breast
cancer
cases
diagnoses
w/in
3
months
a/er
post-‐biopsy
imaging,
N
7397
RTAS
3604
40
18
Rate
per
1000
imaging
exams
(95%
CI)
Invasive
cancer
(nonmissing),
N
Percent
(95%
CI)
5.4
(3.9,
7.4)
26
(40)
5.0
(3.0,
7.9)
12
(18)
65%
(48%,
79%)
67%
(41%,
87%)
Breast
Cancer
w/in
3
months
aYer
post-‐biopsy
imaging
SIFU
Among
invasive
cancers
Node
posi=ve
(non
missing),
N
Percent
(95%
CI)
Late
stage
(III
or
IV)
(non
missing),
N
Percent
(95%
CI)
Large
size
(≥20
mm)
(non
missing),
N
Percent
(95%
CI)
7
(23)
30%
(13%,
53%)
4
(22)
18%
(5%,
40%)
4
(22)
18%
(5%,
40%)
3
(10)
30%
(7%,
76%)
3
(10)
30%
(7%,
65%)
3
(11)
27%
(6%,
61%)
RTAS
Conclusion
• Our
results
do
not
show
a
staKsKcally
significant
difference
in
the
rate
of
ipsilateral
cancer
detecKon
between
SIFU
and
RTAS
following
a
benign
breast
biopsy.
• Rates
of
invasive
cancer
and
posiKve
nodal
status
also
did
not
achieve
staKsKcal
significance
between
the
groups.
Conclusion
2
• Having
a
benign
breast
biopsy
is
a
posiKve
risk
factor
for
breast
cancer
(Breast
Cancer
Risk
Assessment
Tool
and
Gail
Model).
• Despite
the
posiKve
relaKve
risk
factor
associated
with
a
biopsy,
the
ideal
method
of
follow-‐up
for
women
with
benign
concordant
breast
biopsies
has
not
been
studied.
• Our
results
suggest
that
the
pracKce
of
SIFU
following
a
benign
biopsy
may
not
offer
significant
advantage
over
RTAS
considering
the
cost
and
Kme
involved.
Strengths
• Large
sample
of
both
paKents
and
radiologists
which
is
representaKve
of
diverse
US
pracKces.
• To
our
knowledge,
this
is
the
first
study
to
assess
the
outcome
differences
between
SIFU
and
RTAS
following
a
benign
concordant
breast
biopsy.
• PaKent,
radiologic,
and
cancer
data
within
the
BCSC
provides
an
opportunity
to
examine
follow-‐ up
outcomes
in
a
large
data
set
collected
in
a
common
format.
Weaknesses
• Small
#
of
cancers
detected
precludes
sub-‐groups
analysis
for
difference
in
outcome
between
groups
(i.e.,
older
versus
younger,
white
versus
non-‐white,
HRT
vs.
no
HRT,
etc.).
• RetrospecKve
nature
has
inherent
weaknesses
including
possibility
of
incorrectly
filed
data
and
missing
data
points.
• Predominance
of
White,
non-‐Hispanic
paKents
(~85%)
in
our
data
set
limits
generalizability
of
our
data
to
non-‐Whites.
Clinical
Relevance
• These
results
suggest
that
the
pracKce
of
SIFU
following
a
benign
biopsy
may
not
offer
significant
advantage
over
RTAS
considering
the
cost
and
Kme
involved.
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