update on percutaneous needle biopsy

8/13/2019 Update on Percutaneous Needle Biopsy

1/13


2/13

lymph node biopsy (SLNB),24 a CNB can help differentiatein situ and invasive carcinomas, especially for patientspresenting with calcifications only, and such patients maynot require an SLNB. The category 6 refers to biopsyconfirmed malignancy. Therefore, pathologists are mostlikely to encounter CNB specimens from BIRADS category

4 and 5 lesions.There are several key words in breast imaging reports

that should raise the pathologists level of concern whenreviewing a CNB and prompt further evaluation of thetissue (additional levels) or discussion with the radiologistwhen radiologic-pathologic correlation is not met. Mam-mography reports will describe the characteristics of themass (shape, border, density, etc.) or the presence ofcalcifications and their features (distribution and form). Ingeneral, worrisome features include irregular masses withspiculated borders and pleomorphic linear or branchingcalcifications.2527 Amorphous calcifications, referring tocalcifications too small to further characterize, are ofintermediate concern and are usually biopsied.26,28

Like mammography, US is another modality used toevaluate mass lesions. Similar features as those described inmammography are reported (shape, margin, and bound-ary). Rather than density, echogenicity in relation tosubcutaneous fat is studied. Isoechoic describes imagingfindings with the same echogenicity as fatty tissue.Anechoic often correlates with cysts and hyperechoiccorrelates with fibroglandular tissue. Most cancers aredescribed as hypoechoic. Additionally, the orientation ofthe mass in relation to the cutaneous surface (parallel vs.nonparallel) is important. Posterior acoustic patterns (nofeatures, enhancement or shadowing) are also reported.Worrisome features of breast lesions on US studies includea hypoechoic pattern, irregular shape, nonparallel orienta-

tion (the lesion is taller than it is wide) and posteriorshadowing.29

MRI of breast lesions is predicated on tumorangiogenesis in neoplasia. This tool is used to observe the

morphologic features and the kinetics of contrast-enhance-ment within a lesion. The shape, border and enhancementcharacteristics are evaluated for masses. Two phases ofkinetics are described, initial (within 2 min of contrastadministration) and delayed (more than 2 min aftercontrast administration.) Initial phase kinetics is reported

as slow, medium or fast. Delayed phase kinetics, referringto a signal intensity curve, is reported as persistent, plateauor wash-out. In short, masses with irregular margins, rimenhancement, fast initial phase kinetics and plateau orwashout delayed kinetics are suspicious findings.30,31 Masslesions smaller than 5 mm and nonmass-like enhancementhave lower likelihood of malignancy. However, theseguidelines should be used with caution. Invasive lobularcarcinoma and ductal carcinoma in situ (DCIS) maypresent as nonmass-like lesions. Invasive lobular carcino-mas may also present with persistent kinetics, typically alow-risk MRI finding.30 With any uncertainty, commu-nication with the radiologist is encouraged. Imagingfeatures characteristic of radiologically suspicious lesions

are summarized in Table 3.

TECHNICAL ASPECTSThere are several technical aspects of CNB that merit

specific comment. First, the sensitivity of the CNBprocedure is in large part related to the size of the needle.Most studies have evaluated the sensitivity of CNB fromthe perspective of underestimation of malignancy (orupgrade rates). Not surprisingly, the underestimation ratesvary with gauge of the needle used and range from 18% to60% with 14-gauge needles.14,3235 These rates are reducedsignificantly with the newer 11-gauge and 9-gauge needlesto between 8% and 39%.8,9,14,3537

Second, if the CNB is performed because of thepresence of mammographic calcifications without a softtissue density, specimen radiography should be perfor-med to confirm the presence of calcifications within the

TABLE 1. Breast Imaging and Reporting System

Category Definition Recommended Follow-up

0 Incomplete evaluation Additional evaluation required1 Normal Normal follow-up2 Typically benign Normal follow-up

3 Probably benign 4 or 6 mo follow-up for mass orcalcifications, respectively

4 Suspicious abnormality Consider biopsy5 Highly suggestive of malignancy Core needle biopsy or excision

recommended6 Biopsy confirmed malignancy

TABLE 2. Breast Imaging and Reporting System, Category 4 Subcategories

Subcategory Definition Clinical Follow-up

4a Low suspicion of malignancy Benign biopsy not necessarilydiscordant. Six-month follow-upif benign biopsy result

4b Intermediate suspicion of malignancy

If benign biopsy result, follow-updependent on radiologic-

pathologic concordance4c Moderate concern but not classicfor malignancy

A malignant biopsy result isexpected

Johnson et al Adv Anat Pathol Volume 16, Number 4, July 2009

184 | www.anatomicpathology.com r 2009 Lippincott Williams & Wilkins


3/13

specimens. In fact, the likelihood that the pathologist willbe able to render a specific diagnosis on this type ofspecimen is significantly greater when calcifications areidentified on the specimen radiograph compared with whenthey are not.38,39 In one study, a specific diagnosis wasrendered in 81% of core biopsies in which calcifications

were present on the specimen radiograph compared withonly 38% of cases in which calcifications were notradiographically identified in the core biopsy specimens.38

It is of great value for the radiologist to submit separatelycores with and without radiographically identified calcifica-tions. Furthermore, the calcifications must be identified bythe pathologist microscopically and their location indicatedin the final pathology report. More telling perhaps, is thelikelihood of a missed malignant diagnosis on CNB fortargeted calcifications. It has been shown that malignantdiagnoses are missed only 1% of the time in the presence ofcalcifications, but are missed significantly more frequently(11%, P


4/13

CNB. Fifty-four percent displayed FEA, ADH, or lobularneoplasia on excision.73 However, given the small numberof patients in this latter study and the preponderance ofdata suggesting close associations between FEA and low-grade carcinoma (either in situ or invasive), we continue torecommend excision when FEA is identified on CNB.Currently, we do not recommend excision for patients with

columnar cell change or columnar cell hyperplasia identi-fied on CNB.

Atypical Ductal HyperplasiaCNB specimens in which ADH is the most significant

diagnosis are the source of a great deal of controversy. Thetargeted lesion is most often mammographic microcalcifi-cations and the issue of concern is whether the diagnosis ofADH is representative of the entire lesion. Numerousstudies have reported upgrades to a worse lesion (ie, DCISor invasive carcinoma) on excisional biopsy when ADH isfound on CNB. Rates vary from 18% to 87% of patientsusing a 14-gauge device.15,3235,74,75 Rates are approxi-

mately halved to between 10% and 39% with the use of11-gauge or 9-gauge needles.8,9,11,14,3537 In the majorityof cases the carcinoma found at excision is DCIS, and

in about one-quarter of cases an invasive cancer isidentified.8,9,11,7678

The identification of patients with ADH on CNB whocan be spared surgical excision continues to be an area ofactive investigation. In an analysis of pathologic featuresof ADH on CNB, Ely et al79 noted that the likelihood offinding carcinoma on excision was related to the extent of

ADH on the CNB. None of the patients in which ADHinvolved 2 or fewer foci on CNB had carcinoma onexcision. In contrast, of the cases with 4 or more foci ofADH on core, 87% had carcinoma on excision. Othershave reported that for ADH on CNB confined to less than3 lobules or ducts and/or in whom all of the mammo-graphic microcalcifications had been removed, none hadDCIS or invasive carcinoma on subsequent excision.80,81

The architectural pattern of ADH has also been studied inthis regard and significant associations between thepresence of micropapillary pattern of ADH and thepresence of DCIS on subsequent excision have beenreported.79,81 More recent studies have placed greateremphasis on mammographic-pathologic correlation as a

way to stratify patients who may be spared excision. Onestudy evaluated the particular type of calcifications andfound that underestimations occurred more often when the

FIGURE 1. A, Flat epithelial atypia on core needle biopsy. Low-power image showing terminal duct lobular units with variably dilatedacini. B, Higher power image illustrates the low-grade cytologic atypia present in the cells lining the dilated acini. Also note themultilayered epithelium, but the lack of any architectural atypia. Subsequent excision demonstrated foci of low nuclear grade ductalcarcinoma in situ, cribriform pattern (C) and lobular carcinoma in situ (D).




5/13

ADH was associated with linear, branching, or granularcalcifications on mammography. In contrast, there were noinstances of upgrade to DCIS on excision when themammogram showed fine rounded calcifications.82 Inanother recent study, Forgeard et al83 stratified patientsaccording to the number of foci of ADH (r2 or >2), the

mammographic size of the lesion (< 6 mm, Z6mm but21 mm) and whether or not the lesion hadbeen completely excised according to postprocedure ima-ging studies in an effort to identify patients with ADH onCNB who could safely avoid surgical excision. In thisretrospective study of patients with targeted microcalcifica-tions found to have ADH on CNB, the authors identified3 subsets of patients: one group with no worse lesion foundon excision (imaging lesion size 6 mm with incompleteremoval or size Z6 mm and 21mm). On the basis of these findings the authorsdeveloped an algorithm for managing patients with ADHon CNB whereby only the third group of patients wouldneed to undergo excision with follow-up for the first 2groups of patients.83 In contrast, a study in which the CNBwas performed using vacuum-assisted devices with 9-gaugeor 11-gauge needles showed no significant difference in therate of upgrade regardless of the extent of the ADH, thoughthe numbers in this study were small. Seven (12.5%) of 56cases with focal ADH were upgraded to carcinoma onexcision compared with 11 (22.4%) of 49 patients withADH, not otherwise specified and 8 (44%) of 18 classified

as suspicious for DCIS.12 Importantly, in this studypostbiopsy imaging had not been performed to assess theextent of residual calcifications.8,12

The studies cited above are all limited by smallnumbers. At this time, reliable radiologic, technical, andpathologic factors predictive of which patients with ADHwill likely have a worse lesion remain elusive. As such, wecurrently continue to recommend excision for all patients inwhom ADH is identified on a CNB specimen.

Ductal Carcinoma In-situAs with ADH, the issue of contention when DCIS is

identified on CNB is the underestimation rate of invasivecarcinoma. Underestimation rates of invasive carcinoma

for CNB showing DCIS range from 10% to 38%.14,24,8493The clinical concern in this situation is that the patient willrequire a second procedure to pursue SLNB if invasion isfound upon excision. Whether or not to perform SLNB atthe time of excision has been questioned.24 As well asrequiring an additional surgical procedure, when SLNB isperformed after excision there is often compromisedsurgical lymph node mapping.94,95 In an effort to choosepatients with DCIS on CNB that would be best served withSLNB, many retrospective studies have been performedexamining pathologic and mammographic features of CNBthat may predict invasion on excision. These featuresinclude the presence of a mammographic mass,85,87,88,92,96

tumor size 1.5 to 5 cm,84,93,96 DCIS of high nuclear

grade,24,92,93,96 the presence of comedo necrosis,97 lobularinvolvement by DCIS,96,97 the presence of periductalinflammation,24,89 and microinvasion.85,92 As discussed

above, many studies report lower underestimation rateswith the use of vacuum-assisted biopsy devices and largergauge needles.

Extensive involvement of the CNB by DCIS has beenshown to correlate with increased likelihood of surgicalmargin involvement at excision.98 One study showed that

those cases of invasive ductal carcinoma with a highproportion of DCIS were more likely to require widerexcision. Other predictive features of DCIS associated withcompromised margins on univariate analysis include highnuclear grade, solid pattern and comedo necrosis.98

All patients with DCIS identified on CNB requiresurgical excision of the area of mammographic abnorm-ality. It is not our practice to perform SNLB at the time ofinitial excision unless microinvasion is present in the CNB.If there is a very high index of suspicion for invasivecarcinoma, repeat CNB may be indicated before definitivesurgery.

Lobular Neoplasia (ALH and LCIS)

As ALH and classical forms of LCIS do not typicallypresent with clinical or radiologic findings, these diagnoseson CNB are, therefore, incidental. A histopathologiccorrelate to the radiologic abnormality should be pursued.If the correlating lesion is benign and would not by itselfrequire excision (such as a fibroadenoma), the managementof the lobular neoplasia remains a matter of debate. Itcould be argued that as these lesions are generallyconsidered to be markers of a bilateral increase in breastcancer risk, surgical excision is not indicated. However,there is a paucity of adequate data regarding the findings insubsequent surgical excision specimens from patients whohave ALH or LCIS identified on CNB. To date, moststudies are retrospective and are clouded by selection bias

based on concomitant imaging features or patient history.In a recent review of the literature by Cangiarella et al,99

cases in which lobular neoplasia on core biopsy wereupgraded to invasive carcinoma or DCIS on excisionranged from 0% to 67% with no significant differencebetween ALH (0% to 67%) and LCIS (0% to 50%). Inanother review of the literature, Elsheikh and Silverman100

report that the incidence of subsequent cancer on CNB ofpure lobular neoplasia (ie, unassociated with other high-risk lesions) is 18%. However, some of the cancersidentified on subsequent excision in this review had beenassociated with mass lesions on imaging studies (i.e.represent radiologic-pathologic discordance) or lobularneoplasia with atypical features (pleomorphic LCIS). Brem

and colleagues reported on a multi-institutional study oflobular neoplasia on CNB. Two hundred and seventy eightpatients had lobular neoplasia as their worst lesion.Excision was performed in only 164 of these cases and aworse lesion was found in 22% of women with ALH and25% of those with LCIS.101 In this study, a higherlikelihood of underestimation was associated with thepresence of a radiologic mass or calcifications, a higherBIRADS category, the use of a nonvacuum-assisted CNBdevice and fewer specimens obtained. However, there wasno group in which the risk of upgrade on excision wassufficiently low, and these authors recommended that allwomen with ALH or LCIS on CNB undergo excision. Incontrast, Nagi and colleagues conducted a very careful

mammographic-pathologic correlation study and foundthat of 98 cases of purely incidental classical lobularneoplasia (ie, with no mammographic abnormalities or

Adv Anat Pathol Volume 16, Number 4, July 2009 Update on Percutaneous Breast Biopsy

r 2009 Lippincott Williams & Wilkins www.anatomicpathology.com |187


6/13

atypical pathologic features such as pleomorphic nuclei orcomedo necrosis), there was a 93% correlation with thepathology findings on excision.102 In only three cases wereworse lesions found in the excision specimen.

It has been proposed that rather than group all casesof incidental lobular neoplasia under one treatment arm,

the pathologic appearance of the lesion be considered whendetermining the clinical management. Under this rubric,lobular neoplasia of the classic type A (small, uniform,bland nuclei) may not require excision.102 Additionalstudies are needed to evaluate this proposal and to assessinterobserver agreement using this classification. Certainly,for patients with a diagnosis of pure ALH or LCIS onCNB, a surgical excision is warranted if there is radiologic-pathologic discordance or if the LCIS has atypical featuressuch as pleomorphic nuclei or necrosis (Fig. 2) which wouldresult in difficulties in distinguishing the lesion fromDCIS.102104 Immunostaining for E-cadherin may be ofvalue in determining whether the cells have a lobular orductal phenotype105107; although, in this situation we

believe it is prudent still to recommend excision if thefeatures on routine histologic sections are not those ofclassical LCIS. In the meantime, our current practice is forall patients with lobular neoplasia on CNB to undergoexcisional biopsy.

Papillary LesionsThe management of patients with papillary lesions

diagnosed on CNB is also an unresolved issue. Papillarylesions are endowed with a myriad of names with differentdiagnostic criteria defined by multiple experts. Furthercomplicating this realm of breast pathology on CNB is thefocal nature of involvement of some papillary lesions byatypia and the tissue fragmentation inherent in CNB,

making the already complex architecture of papillarylesions more difficult to interpret. The primary distinctionto be made with papillary lesions on CNB is to differentiatethose lesions with from those without atypia, especially forinstitutions that do not routinely excise all benignpapillomas diagnosed on CNB. Further classifying anatypical papillary lesion into atypical papilloma, papilloma

with DCIS, papillary DCIS, encapsulated papillary carci-noma (intracystic papillary carcinoma) and frankly invasivepapillary carcinoma can be quite difficult on CNB due tothe limited, often fragmented tissue available and thelikelihood that the periphery of the lesion is not evaluable(Fig. 3). In some cases, immunohistochemical studies for

myoepithelial markers or high molecular weight cytoker-atins (CK 5/6, CK 14, 34bE12) and estrogen receptor mayhelp to sort out this differential diagnosis. Lesions with lowor intermediate nuclear grade DCIS will lack staining withhigh molecular weight cytokeratins and will show strongexpression of estrogen receptor; whereas benign papillomaswill show a mosaic staining pattern with high molecularweight cytokeratins and will have only focal expression ofestrogen receptor.108110 However, tissue sampling will stillbe an issue. Fortunately, this distinction is not as critical onCNB as most experts would agree that a papillary lesionwith any degree of atypia calls for surgical excision forcomplete evaluation and definitive classification. In addi-tion, special attention should be paid to the surrounding

tissue, as atypia outside the papillary lesion may serve as abetter prognostic indicator.111,112

The issue of whether to excise benign papillomasfound on CNB remains controversial. Some more recentstudies have cautiously suggested that patients with adiagnosis of a benign papilloma on CNB may be followed ifthe imaging studies are concordant. In one study, none ofthe 18 patients (0%) who had a benign papilloma on CNBand who had a subsequent surgical excision were found tohave carcinoma. In contrast, 2 of 7 cases (29%) withpapilloma with separate foci of atypia and 12 of 13 cases(92%) diagnosed as severely atypical papilloma suspiciousfor carcinoma were found to have carcinoma on excisionalbiopsy.113 In another study, 6 of 30 (20%) patients with

benign papillomas on CNB underwent subsequent exci-sional biopsy, all of which revealed no atypia. Theremaining patients (those without surgical excision) hadno evidence of disease progression on clinical andradiologic follow-up.114 Carder et al115 reported 16 benignor indeterminate papillomas on CNB of which 4 displayedADH at excision, but no carcinoma was identified at

FIGURE 2. Lobular carcinoma in situ (LCIS), with comedo necrosis on core needle biopsy (CNB) (A). Low-power image displays aterminal duct lobular unit distended by an atypical epithelial proliferation with comedo necrosis. At the lower edge of the CNB an areaof classical LCIS is present. (B) Higher power image shows large, poorly cohesive epithelial cells with ample eosinophilic cytoplasm,eccentric nuclei, and rare intracytoplasmic vacuoles morphologically consistent with LCIS. These variant forms of LCIS can be difficult todifferentiate from ductal carcinoma in situ.




7/13

excision in any of these cases. In contrast, in other studies,unexpectedly high rates of atypia or malignancy wereidentified at excision among patients with diagnoses ofbenign papilloma on CNB (eg, 5 of 28 patients, 17.9% in

one study116 and 15 of 80 patients, 19% in another117). Ofnote, these studies only included patients with 14-gaugeautomated needle biopsy specimens. More recent studiesevaluating this issue have reported upgrade rates varying

FIGURE 3. Papillary lesions can be difficult to classify on core needle biopsy. This image represents a fragment of a papillary lesion (A)with usual ductal hyperplasia (lower right of field) and with focal areas of cytologic atypia (upper left of field) seen on high power (B).

FIGURE 4. Core needle biopsy may not completely sample a complex sclerosing lesion/radial scar as illustrated in these examples. A,Radial scar on core needle biopsy. B, Radial scars/complex sclerosing lesions can exhibit focal involvement by atypical ductal hyperplasia(upper left of field) and lobular neoplasia (lower right of field), C, Higher power image of the area of lobular neoplasia. D, Radial scarinvolved by DCIS.




8/13

between 6% and 36%, although it should be pointed outthat several of these studies are limited by lack ofpathologic review.118123. It has been suggested that forthose benign papillomas without atypia diagnosed on CNB,complete removal by large gauge vacuum-assisted devicecould be considered, offering a less invasive method of

excision for patients with a low probability of cancer whileallowing for further evaluation of the remaining papillarylesion along with some surrounding tissue.49 Thus, whilesome studies suggest that patients with benign papillomadiagnosed on CNB may be spared excision, currently werecommend that all radiologically targeted papillary lesionsdiagnosed on CNB should be excised.

Radial Scars/Complex Sclerosing LesionsThe occurrence of invasive or in situ carcinoma

involving radial scars or in close proximity to radial scarsis well known, with rates ranging from 0% to 34%,124130

and with variable association with older patient age andlarger lesion size.128,131 Although the association with

carcinoma is known, the possibility of underdiagnosis onCNB is not surprising given that involvement of the radialscar by carcinoma is often only focal or peripheral(Fig. 4).131 Retrospective studies examining surgical exci-sion following a diagnosis of radial scar without atypiadiagnosed on CNB reveal rates of upgrade to invasivecarcinoma ranging from 0% to 12%.124130,132 As discussedabove for other lesions associated with an upgrade rate,missed carcinomas after a diagnosis of radial scar on CNBare more likely with 14-gauge automatic spring-loadedbiopsy devices versus larger gauge vacuum-assisted devicesand with fewer than 12 tissue samples.124,132,133 Thissuggests the possibility that excision by vacuum-assisteddevices with careful clinical follow-up may be feasible

for those patients with radial scars without atypia onvacuum-assisted biopsy and pathologic-mammographiccorrelation.132

However, given the very limited data available at thistime, we believe it is prudent for all patients with radialscars diagnosed on CNB to undergo surgical excision toexclude the possibility of concomitant carcinoma.

Fibroepithelial LesionsWhen a fibroadenoma is diagnosed on CNB and the

imaging findings are concordant with that diagnosis, nofurther surgery is required. Issues arise when the CNB

shows a fibroepithelial lesion with increased stromalcellularity for which the differential diagnosis includesbenign phyllodes tumor or phyllodes tumors of uncertainmalignant potential. Malignant phyllodes tumors are notusually a diagnostic problem. Features on CNB that havebeen shown to be associated with phyllodes tumor includemarkedly increased stromal cellularity, stromal cell atypia,and mitoses and also a high proportion of stroma toepithelium.134 Further features that suggest phyllodestumor on CNB are increased stromal cellularity comparedwith that of a typical fibroadenoma in at least 50% of thespecimen, stromal overgrowth (ie, at least one 10 fieldwith no glands), adipose tissue within the stroma and tissuefragmentation135 (Table 4). However, none of the above

mentioned features can predict with absolute reliability thelikelihood of having a benign phyllodes tumor versus afibroadenoma on excision (Fig. 5). Therefore, any fibro-epithelial lesion in which the differential diagnosis includesphyllodes tumor must be excised for complete evalua-tion.134139 Repeat biopsy does not seem to be helpful.135

Histologic features strongly suspicious for phyllodes tumor

TABLE 4. Features of Fibroepithelial Lesions on Core NeedleBiopsy Reported to be Associated With Phyllodes Tumor onExcision

Jacobs et al134

Markedly increased stromal cellularityHigh proportion of stroma to epitheliumStromal cytologic atypiaStromal mitoses

Lee et al135

Increased stromal cellularity involving at least 50% of tissueStromal overgrowth (10 field without glands)Fragmentation of tissueAdipose tissue within the stroma

FIGURE 5. A cellular fibroepithelial lesion sampled by core needle biopsy demonstrating a fairly cellular stroma with compressedepithelial ducts and condensation of stroma around the ducts (A) and stromal overgrowth (B). Fibroadenoma was diagnosed onexcision.




9/13

should be reported so that clear margins can be attemptedin these cases. Regarding fibroadenomas, aside fromexcluding phyllodes tumors, features of complex fibroa-denomas which include sclerosing adenosis, calcificationsassociated with epithelium, cysts greater than 3 mm andpapillary apocrine metaplasia, might be mentioned due tothe slight increase in risk for subsequent carcinoma thatthese lesions incur.140

Mucocele-like LesionsMLLs are composed of mucin containing cysts which

may rupture, with extravasation of mucin into surroundingstroma (Fig. 6).141 The imaging target may be indetermi-nate calcifications or a nodular mass. The epithelium liningthe cysts of MLLs is often attenuated but may range frombenign to ADH to DCIS.142 The reason management issuesarise in this scenario are the concern as to whether theremay be undersampling of areas of mucinous carcinoma. Ofnote, the presence of epithelial cells floating in pools ofmucin may be attributable either to stripped epitheliumfrom a benign MLL in a fragmented CNB specimen or tomucinous carcinoma. One small study reported that 30% ofMLLs were found to be mucinous carcinoma on exision,143

though others have claimed that mucinous lesions can beaccurately classified on the basis of the CNB.91,144 Thelargest study to date by Wang et al91 reviewed the CNB andsurgical excision of 32 mucinous lesions, of which 29diagnoses made on CNB were unchanged with excision.The remaining cases were diagnosed as MLL withoutatypia on CNB and only showed fibrocystic change onexcision. In those cases that display disrupted mucin pools,

the presence of capillaries within the mucinous stroma mayoffer a clue to the malignant nature of the lesion.145 Giventhe very small numbers in these studies, it is recommendedthat an excision to rule out mucinous DCIS or mucinouscarcinoma be performed after the identification of MLL orstromal pools of mucin on CNB.

Other Benign Mass-like LesionsWith the strong emphasis on radiologic-pathologic

correlation when interpreting CNB specimens, it is im-portant to keep in mind other entities that may form masslesions aside from malignancy and those described above.Cysts, pseudoangiomatous stromal hyperplasia, fat necrosisand nodular adenosis can form a palpable mass or a masslesion identified on imaging studies. Recognition of theselesions and their careful correlation with the imagingfindings can prevent an unnecessary surgical excision.Table 5 summarized the non-malignant breast lesions forwhich excision is recommended.

In conclusion, when rendering an opinion on a CNB

of the breast, the pathologist should always correlate theradiologic findings with those seen on the histologicsections and provide sufficient information to ensure thepatient is triaged into the appropriate management path-way.

ACKNOWLEDGMENT

The authors wish to express their thanks to Dr StuartSchnitt for reviewing and commenting on this manuscriptduring its preparation.

REFERENCES

1. Dershaw DD, Liberman L. Stereotactic breast biopsy:indications and results. Oncology (Huntingt). 1998;12:907922.

2. Meyer JE, Smith DN, Lester SC, et al. Large-core needlebiopsy of nonpalpable breast lesions. JAMA. 1999;281:16381641.

3. Wong AY, Salisbury E, Bilous M. Recent developments instereotactic breast biopsy methodologies: an update for thesurgical pathologist. Adv Anat Pathol. 2000;7:2635.

4. Liberman L. Centennial dissertation. Percutaneous imaging-guided core breast biopsy: state of the art at the millennium.AJR Am J Roentgenol. 2000;174:11911199.

5. Hoda SA, Rosen PP. Practical considerations in thepathologic diagnosis of needle core biopsies of breast. Am JClin Pathol. 2002;118:101108.

6. Liberman L, Goodstine SL, Dershaw DD, et al. One

operation after percutaneous diagnosis of nonpalpable breastcancer: frequency and associated factors. AJR Am J Roentgenol. 2002;178:673679.

7. Liberman L, Holland AE, Marjan D, et al. Underestimationof atypical ductal hyperplasia at MRI-guided 9-gaugevacuum-assisted breast biopsy. AJR Am J Roentgenol.2007;188:684690.

8. Eby PR, Ochsner JE, DeMartini WB, et al. Frequency andupgrade rates of atypical ductal hyperplasia diagnosed atstereotactic vacuum-assisted breast biopsy: 9-versus 11-gauge.AJR Am J Roentgenol. 2009;192:229234.

9. Brem RF, Behrndt VS, Sanow L, et al. Atypical ductalhyperplasia: histologic underestimation of carcinoma in tissueharvested from impalpable breast lesions using 11-gaugestereotactically guided directional vacuum-assisted biopsy.AJR Am J Roentgenol. 1999;172:14051407.

10. Perretta T, Pistolese CA, Bolacchi F, et al. MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histologicalcharacterisation. Radiol Med. 2008;113:830840.

FIGURE 6. This image shows stromal pools of mucin sampled bycore needle biopsy. Lesions of this type require excision toexclude the possibility of mucinous carcinoma.

TABLE 5. Nonmalignant Breast Lesions for Which Excision isRecommended

Flat epithelial atypiaAtypical ductal hyperplasiaLobular neoplasia (including ALH and LCIS)PapillomaRadial scar/complex sclerosing lesionCellular fibroepithelial lesionMucocele-like lesion

ALH indicates atypical lobular hyperplasia; LCIS, lobular carcinoma insitu.




10/13

11. Darling ML, Smith DN, Lester SC, et al. Atypical ductalhyperplasia and ductal carcinoma in situ as revealed by large-core needle breast biopsy: results of surgical excision. AJRAm J Roentgenol. 2000;175:13411346.

12. Eby PR, Ochsner JE, DeMartini WB, et al. Is surgicalexcision necessary for focal atypical ductal hyperplasia foundat stereotactic vacuum-assisted breast biopsy? Ann Surg

Oncol. 2008;15:32323238.13. Lourenco AP, Mainiero MB, Lazarus E, et al. Stereotactic

breast biopsy: comparison of histologic underestimation rateswith 11- and 9-gauge vacuum-assisted breast biopsy. AJR AmJ Roentgenol. 2007;189:W275W279.

14. Houssami N, Ciatto S, Ellis I, et al. Underestimation ofmalignancy of breast core-needle biopsy: concepts and preciseoverall and category-specific estimates. Cancer. 2007;109:487495.

15. Jackman RJ, Nowels KW, Rodriguez-Soto J, et al. Stereo-tactic, automated, large-core needle biopsy of nonpalpablebreast lesions: false-negative and histologic underestimationrates after long-term follow-up.Radiology.1999;210:799805.

16. Jacobs TW, Siziopikou KP, Prioleau JE, et al. Do prognosticmarker studies on core needle biopsy specimens of breast

carcinoma accurately reflect the marker status of the tumor?Mod Pathol. 1998;11:259264.

17. Lerwill MF. Current practical applications of diagnosticimmunohistochemistry in breast pathology. Am J SurgPathol. 2004;28:10761091.

18. Chivukula M, Bhargava R, Brufsky A, et al. Clinicalimportance of HER2 immunohistologic heterogeneous ex-pression in core-needle biopsies vs resection specimens forequivocal (immunohistochemical score 2+) cases. ModPathol. 2008;21:363368.

19. Chivukula M, Haynik DM, Brufsky A, et al. Pleomorphiclobular carcinoma in situ (PLCIS) on breast core needlebiopsies: clinical significance and immunoprofile. Am J SurgPathol. 2008;32:17211726.

20. Sutela A, Vanninen R, Sudah M, et al. Surgical specimen canbe replaced by core samples in assessment of ER, PR and

HER-2 for invasive breast cancer.Acta Oncol.2008;47:3846.21. Park SY, Kim KS, Lee TG, et al. The accuracy of

preoperative core biopsy in determining histologic grade,hormone receptors, and human epidermal growth factorreceptor 2 status in invasive breast cancer. Am J Surg.2009;197:266269.

22. Rakha EA, Ellis IO. An overview of assessment of prognosticand predictive factors in breast cancer needle core biopsyspecimens.J Clin Pathol. 2007;60:13001306.

23. Collins LC, Connolly JL, Page DL, et al. Diagnosticagreement in the evaluation of image-guided breast coreneedle biopsies: results from a randomized clinical trial. Am JSurg Pathol. 2004;28:126131.

24. Hoorntje LE, Schipper ME, Peeters PH, et al. The finding ofinvasive cancer after a preoperative diagnosis of ductal

carcinoma-in-situ: causes of ductal carcinoma-in-situ under-estimates with stereotactic 14-gauge needle biopsy. Ann SurgOncol. 2003;10:748753.

25. Balleyguier C, Ayadi S, Van Nguyen K, et al. BIRADSclassification in mammography.Eur J Radiol. 2007;61:192194.

26. Tse GM, Tan PH, Pang AL, et al. Calcification in breastlesions: pathologists perspective. J Clin Pathol. 2008;61:145151.

27. Tse GM, Tan PH, Cheung HS, et al. Intermediate to highlysuspicious calcification in breast lesions: a radio-pathologiccorrelation.Breast Cancer Res Treat. 2008;110:17.

28. Berg WA, Arnoldus CL, Teferra E, et al. Biopsy ofamorphous breast calcifications: pathologic outcome andyield at stereotactic biopsy. Radiology. 2001;221:495503.

29. Levy L, Suissa M, Chiche JF, et al. BIRADS ultrasono-graphy. Eur J Radiol. 2007;61:202211.

30. Agrawal G, Su MY, Nalcioglu O, et al. Significance of breastlesion descriptors in the ACR BI-RADS MRI lexicon.Cancer. 2009;115:13631380.

31. Tardivon AA, Athanasiou A, Thibault F, et al. Breastimaging and reporting data system (BIRADS): magneticresonance imaging. Eur J Radiol. 2007;61:212215.

32. Burbank F. Stereotactic breast biopsy: comparison of 14- and11-gauge Mammotome probe performance and complicationrates. Am Surg. 1997;63:988995.

33. Liberman L, Cohen MA, Dershaw DD, et al. Atypical ductal

hyperplasia diagnosed at stereotaxic core biopsy of breastlesions: an indication for surgical biopsy (see comments). AJRAm J Roentgenol. 1995;164:11111113.

34. Jackman RJ, Nowels KW, Shepard MJ, et al. Stereotaxiclarge-core needle biopsy of 450 nonpalpable breast lesionswith surgical correlation in lesions with cancer or atypicalhyperplasia.Radiology. 1994;193:9195.

35. Margolin FR, Kaufman L, Jacobs RP, et al. Stereotactic corebreast biopsy of malignant calcifications: diagnostic yield ofcores with and cores without calcifications on specimenradiographs.Radiology. 2004;233:251254.

36. Burak WE Jr, Owens KE, Tighe MB, et al. Vacuum-assistedstereotactic breast biopsy: histologic underestimation ofmalignant lesions. Arch Surg. 2000;135:700703.

37. Nath ME, Robinson TM, Tobon H, et al. Automated large-

core needle biopsy of surgically removed breast lesions:comparison of samples obtained with 14-, 16-, and 18-gaugeneedles.Radiology. 1995;197:739742.

38. Liberman L, Evans WP III, Dershaw DD, et al. Radiographyof microcalcifications in stereotaxic mammary core biopsyspecimens.Radiology. 1994;190:223225.

39. Mainiero MB, Philpotts LE, Lee CH, et al. Stereotaxic coreneedle biopsy of breast microcalcifications: correlation oftarget accuracy and diagnosis with lesion size. Radiology.1996;198:665669.

40. Dahlstrom JE, Sutton S, Jain S. Histologic-radiologic correla-tion of mammographically detected microcalcification instereotactic core biopsies. Am J Surg Pathol. 1998;22:256259.

41. Dahlstrom JE, Jain S. Histological correlation of mammo-graphically detected microcalcifications in stereotactic corebiopsies.Pathology. 2001;33:444448.

42. Liu X, Inciardi M, Bradley JP, et al. Microcalcifications of thebreast: size matters! A mammographic-histologic correlationstudy.Pathologica. 2007;99:510.

43. DOrsi CJ, Reale FR, Davis MA, et al. Breast specimenmicrocalcifications: radiographic validation and pathologic-radiologic correlation. Radiology. 1991;180:397401.

44. Berg WA. When is core breast biopsy or fine-needleaspiration not enough? Radiology. 1996;198:313315.

45. Rakha E, El-Sayad M, Reed J, et al. Screen-detected breastlesions with malignant needle core biopsy diagnoses and nomalignancy identified in subsequent surgical excision specimens(potential false-positive diagnosis).Eur J Cancer. 2009; e-pub.

46. Reynolds HE. Core needle biopsy of challenging benignbreast conditions: a comprehensive literature review. AJR AmJ Roentgenol. 2000;174:12451250.

47. Jacobs TW, Connolly JL, Schnitt SJ. Non-malignant lesionsin breast core needle biopsies: to excise or not to excise.Am JSurg Pathol. 2002;26:10951110.

48. Alonso-Bartolome P, Vega-Bolivar A, Torres-Tabanera M, etal. Sonographically guided 11-G directional vacuum-assistedbreast biopsy as an alternative to surgical excision: utility andcost study in probably benign lesions. Acta Radiol. 2004;45:390396.

49. Carder PJ, Khan T, Burrows P, et al. Large volumemammotome biopsy may reduce the need for diagnosticsurgery in papillary lesions of the breast. J Clin Pathol.2008;61:928933.

50. Kim MJ, Kim EK, Lee JY, et al. Breast lesions with imaging-histologic discordance during US-guided 14G automated corebiopsy: can the directional vacuum-assisted removal replacethe surgical excision? Initial findings. Eur Radiol. 2007;

17:23762383.51. Povoski SP, Jimenez RE. A comprehensive evaluation of

the 8-gauge vacuum-assisted Mammotome(R) system for




11/13

ultrasound-guided diagnostic biopsy and selective excision ofbreast lesions. World J Surg Oncol. 2007;5:83.

52. Ferzli GS, Hurwitz JB. Initial experience with breast biopsyutilizing the advanced breast biopsy instrumentation (ABBI).Surg Endosc. 1997;11:393396.

53. Damascelli B, Frigerio LF, Patelli G, et al. Stereotactic breastbiopsy: en bloc excision of microcalcifications with a large-bore

cannula device. AJR Am J Roentgenol. 1999;173:895900.54. Doridot V, Meunier M, El Khoury C, et al. Stereotactic

radioguided surgery by SiteSelect for subclinical mammo-graphic lesions. Ann Surg Oncol. 2005;12:181188.

55. Corn CC. Review of 125 SiteSelect stereotactic large-corebreast biopsy procedures. Breast J. 2003;9:147152.

56. Kontos M, Felekouras E, Fentiman IS. Radiofrequencyablation in the treatment of primary breast cancer: no surgicalredundancies yet. Int J Clin Pract. 2008;62:816820.

57. Marcy PY, Magne N, Castadot P, et al. Ultrasound-guidedpercutaneous radiofrequency ablation in elderly breast cancerpatients: preliminary institutional experience. Br J Radiol.2007;80:267273.

58. Van der Ploeg IM, Van Esser S, Van den Bosch MA, et al.Radiofrequency ablation for breast cancer: a review of the

literature.Eur J Surg Oncol. 2007;33:673677.59. Tavassoli FA, Hoefler H, Rosai J, et al. Intraductal

proliferative lesions. In: Tavassoli FA, Devilee P, eds.Pathology and Genetics: Tumours of the Breast and FemaleGenital Organs. Lyon: IARC Press; 2003:6373.

60. Fraser JL, Raza S, Chorny K, et al. Columnar alteration withprominent apical snouts and secretions: a spectrum ofchanges frequently present in breast biopsies performed formicrocalcifications.Am J Surg Pathol. 1998;22:15211527.

61. Abdel-Fatah TM, Powe DG, Hodi Z, et al. Morphologic andmolecular evolutionary pathways of low nuclear gradeinvasive breast cancers and their putative precursor lesions:further evidence to support the concept of low nucleargrade breast neoplasia family. Am J Surg Pathol. 2008;32:513523.

62. Goldstein NS, OMalley BA. Cancerization of small ectatic

ducts of the breast by ductal carcinoma in situ cells withapocrine snouts: a lesion associated with tubular carcinoma.Am J Clin Pathol. 1997;107:561566.

63. Oyama T, Maluf H, Koerner F. Atypical cystic lobules: anearly stage in the formation of low-grade ductal carcinoma insitu. Virchows Arch. 1999;435:413421.

64. Rosen PP. Columnar cell hyperplasia is associated withlobular carcinoma in situ and tubular carcinoma.Am J SurgPathol. 1999;23:1561.

65. De Mascarel I, MacGrogan G, Mathoulin-Pelissier S, et al.Epithelial atypia in biopsies performed for microcalcifica-tions. Practical considerations about 2833 serially sectionedsurgical biopsies with a long follow-up. Virchows Arch.2007;451:1-10.

66. Sahoo S, Recant WM. Triad of columnar cell alteration,

lobular carcinoma in situ, and tubular carcinoma of thebreast.Breast J. 2005;11:140142.

67. Brandt SM, Young GQ, Hoda SA. The rosen triad: tubularcarcinoma, lobular carcinoma in situ, and columnar celllesions. Adv Anat Pathol. 2008;15:140146.

68. Harigopal MYD, Hoda SA, DeLellis RA, et al. Columnar cellalteration diagnosed on mammotome core biopsy forindeterminate microcalcifications: results of subsequent mam-mograms and surgical excision.Mod Pathol. 2002;15:36A.

69. Brogi E, Tan LK. Findings at excisional biopsy (EBX)performed after identification of columnar cell change (CCC)of ductal epithelium in breast core biopsy (CBX). Meetingabstract.Mod Pathol. 2002;15:29A30A.

70. Kunju LP, Kleer CG. Significance of flat epithelial atypia onmammotome core needle biopsy: should it be excised? HumPathol. 2007;38:3541.

71. Martel M, Barron-Rodriguez P, Tolgay Ocal I, et al. FlatDIN 1 (flat epithelial atypia) on core needle biopsy: 63 casesidentified retrospectively among 1751 core biopsies performed

over an 8-year period (19921999). Virchows Arch. 2007;451:883891.

72. Pinder SE, Provenzano E, Reis-Filho JS. Lobular in situneoplasia and columnar cell lesions: diagnosis in breast corebiopsies and implications for management. Pathology. 2007;39:208216.

73. Senetta R, Campanino PP, Mariscotti G, et al. Columnar cell

lesions associated with breast calcifications on vacuum-assisted core biopsies: clinical, radiographic, and histologicalcorrelations.Mod Pathol. 2009. Mar 13, e-pub.

74. Dahlstrom JE, Sutton S, Jain S. Histological precision ofstereotactic core biopsy in diagnosis of malignant andpremalignant breast lesions. Histopathology. 1996;28:537541.

75. Moore MM, Hargett CW III, Hanks JB, et al. Association ofbreast cancer with the finding of atypical ductal hyperplasia atcore breast biopsy. Ann Surg. 1997;225:726731; discussion731733.

76. Liberman L, Smolkin JH, Dershaw DD, et al. Calcificationretrieval at stereotactic, 11-gauge, directional, vacuum-assisted breast biopsy. Radiology. 1998;208:251260.

77. Burbank F. Stereotactic breast biopsy of atypical ductalhyperplasia and ductal carcinoma in situ lesions: improved

accuracy with directional, vacuum-assisted biopsy.Radiology.1997;202:843847.

78. Adrales G, Turk P, Wallace T, et al. Is surgical excisionnecessary for atypical ductal hyperplasia of the breastdiagnosed by Mammotome? Am J Surg. 2000;180:313315.

79. Ely KA, Carter BA, Jensen RA, et al. Core biopsy ofthe breast with atypical ductal hyperplasia: a probabilisticapproach to reporting. A m J Surg Pathol. 2001;25:10171021.

80. Sneige N, Lim SC, Whitman GJ, et al. Atypical ductalhyperplasia diagnosis by directional vacuum-assisted stereo-tactic biopsy of breast microcalcifications. Considerations forsurgical excision. Am J Clin Pathol. 2003;119:248253.

81. Wagoner MJ, Laronga C, Acs G. Extent and histologicpattern of atypical ductal hyperplasia present on core needlebiopsy specimens of the breast can predict ductal carcinoma

in situ in subsequent excision. Am J Clin Pathol. 2009;131:112121.

82. Hoang JK, Hill P, Cawson JN. Can mammographic findingshelp discriminate between atypical ductal hyperplasia andductal carcinoma in situ after needle core biopsy? Breast.2008;17:282288.

83. Forgeard C, Benchaib M, Guerin N, et al. Is surgical biopsymandatory in case of atypical ductal hyperplasia on 11-gaugecore needle biopsy? A retrospective study of 300 patients.AmJ Surg. 2008;196:339345.

84. Dillon MF, McDermott EW, Quinn CM, et al. Predictors ofinvasive disease in breast cancer when core biopsy demon-strates DCIS only. J Surg Oncol. 2006;93:559563.

85. Doyle B, Al-Mudhaffer M, Kennedy MM, et al. Sentinellymph node biopsy in patients with a needle core biopsy

diagnosis of DCISis it justified? J Clin Pathol. 2009. Mar18, e-pub.

86. Farkas EA, Stolier AJ, Teng SC, et al. An argument againstroutine sentinel node mapping for DCIS. Am Surg. 2004;70:1317; discussion 17-8.

87. Goyal A, Douglas-Jones A, Monypenny I, et al. Is there a roleof sentinel lymph node biopsy in ductal carcinoma in situ?Analysis of 587 cases. Breast Cancer Res Treat. 2006;98:311314.

88. Jackman RJ, Burbank F, Parker SH, et al. Stereotacticbreast biopsy of nonpalpable lesions: determinants of ductalcarcinoma in situ underestimation rates. Radiology. 2001;218:497502.

89. Lee CH, Carter D, Philpotts LE, et al. Ductal carcinoma insitu diagnosed with stereotactic core needle biopsy: caninvasion be predicted? Radiology. 2000;217:466470.

90. Mittendorf EA, Arciero CA, Gutchell V, et al. Core biopsydiagnosis of ductal carcinoma in situ: an indication forsentinel lymph node biopsy. Curr Surg. 2005;62:253257.




12/13

91. Wang J, Simsir A, Mercado C, et al. Can core biopsy reliablydiagnose mucinous lesions of the breast? Am J Clin Pathol.2007;127:124127.

92. Wilkie C, White L, Dupont E, et al. An update of sentinellymph node mapping in patients with ductal carcinoma insitu.Am J Surg. 2005;190:563566.

93. Yen TW, Hunt KK, Ross MI, et al. Predictors of invasive

breast cancer in patients with an initial diagnosis of ductalcarcinoma in situ: a guide to selective use of sentinel lymphnode biopsy in management of ductal carcinoma in situ.J AmColl Surg. 2005;200:516526.

94. Estourgie SH, Valdes Olmos RA, Nieweg OE, et al. Excisionbiopsy of breast lesions changes the pattern of lymphaticdrainage. Br J Surg. 2007;94:10881091.

95. Feldman SM, Krag DN, McNally RK, et al. Limitation ingamma probe localization of the sentinel node in breastcancer patients with large excisional biopsy.J Am Coll Surg.1999;188:248254.

96. Huo L, Sneige N, Hunt KK, et al. Predictors of invasion inpatients with core-needle biopsy-diagnosed ductal carcinomain situ and recommendations for a selective approach tosentinel lymph node biopsy in ductal carcinoma in situ.

Cancer. 2006;107:17601768.97. Renshaw AA. Predicting invasion in the excision speci-

men from breast core needle biopsy specimens with onlyductal carcinoma in situ. Arch Pathol Lab Med. 2002;126:3941.

98. Dillon MF, Maguire AA, McDermott EW, et al. Needle corebiopsy characteristics identify patients at risk of compromisedmargins in breast conservation surgery. Mod Pathol.2008;21:3945.

99. Cangiarella J, Guth A, Axelrod D, et al. Is surgical excisionnecessary for the management of atypical lobular hyperplasiaand lobular carcinoma in situ diagnosed on core needlebiopsy? A report of 38 cases and review of the literature.ArchPathol Lab Med. 2008;132:979983.

100. Elsheikh TM, Silverman JF. Follow-up surgical excision isindicated when breast core needle biopsies show atypical

lobular hyperplasia or lobular carcinoma in situ: a correlativestudy of 33 patients with review of the literature. Am J SurgPathol. 2005;29:534543.

101. Brem RF, Lechner MC, Jackman RJ, et al. Lobular neoplasiaat percutaneous breast biopsy: variables associated withcarcinoma at surgical excision. AJR Am J Roentgenol.2008;190:637641.

102. Nagi CS, ODonnell JE, Tismenetsky M, et al. Lobularneoplasia on core needle biopsy does not require excision.Cancer. 2008;112:21522158.

103. Liberman L, Sama M, Susnik B, et al. Lobular carcinoma insitu at percutaneous breast biopsy: surgical biopsy findings.AJR Am J Roentgenol. 1999;173:291299.

104. Menon S, Porter GJ, Evans AJ, et al. The significance oflobular neoplasia on needle core biopsy of the breast.

Virchows Arch. 2008;452:473479.105. Jacobs TW, Pliss N, Kouria G, et al. Carcinomas in situ of the

breast with indeterminate features: role of E-cadherin stainingin categorization. Am J Surg Pathol. 2001;25:229236.

106. Sneige N, Wang J, Baker BA, et al. Clinical, histopathologic,and biologic features of pleomorphic lobular (ductal-lobular)carcinoma in situ of the breast: a report of 24 cases. ModPathol. 2002;15:10441050.

107. Hanby AM, Hughes TA. In situ and invasive lobularneoplasia of the breast.Histopathology. 2008;52:5866.

108. Tan PH, Aw MY, Yip G, et al. Cytokeratins in papillarylesions of the breast: is there a role in distinguishingintraductal papilloma from papillary ductal carcinoma insitu? Am J Surg Pathol. 2005;29:625632.

109. Tse GM, Tan PH, Moriya T. The role of immunohistochem-istry in the differential diagnosis of papillary lesions of the

breast.J Clin Pathol. 2009;62:407413.110. Mulligan AM, OMalley FP. Papillary lesions of the breast: a

review. Adv Anat Pathol. 2007;14:108119.

111. Page DL, Salhany KE, Jensen RA, et al. Subsequent breastcarcinoma risk after biopsy with atypia in a breast papilloma.Cancer. 1996;78:258266.

112. MacGrogan G, Tavassoli FA. Central atypical papillomas ofthe breast: a clinicopathological study of 119 cases.VirchowsArch. 2003;443:609617.

113. Renshaw AA, Derhagopian RP, Tizol-Blanco DM, et al.

Papillomas and atypical papillomas in breast core needlebiopsy specimens: risk of carcinoma in subsequent excision.Am J Clin Pathol. 2004;122:217221.

114. Ivan D, Selinko V, Sahin AA, et al. Accuracy of core needlebiopsy diagnosis in assessing papillary breast lesions: histo-logic predictors of malignancy.Mod Pathol.2004;17:165171.

115. Carder PJ, Garvican J, Haigh I, et al. Needle core biopsy canreliably distinguish between benign and malignant papillarylesions of the breast. Histopathology. 2005;46:320327.

116. Ioffe OB, Berg WA, Silverberg SG, et al. Analysis of papillarylesions diagnosed on core needle biopsy of the breast:management implications (Meeting Abstract). Mod Pathol.2000;13:23A.

117. Skandarajah AR, Field L, Yuen Larn Mou A, et al. Benignpapilloma on core biopsy requires surgical excision.Ann Surg

Oncol. 2008;15:22722277.118. Mercado CL, Hamele-Bena D, Oken SM, et al. Papillary

lesions of the breast at percutaneous core-needle biopsy.Radiology. 2006;238:801808.

119. Kil WH, Cho EY, Kim JH, et al. Is surgical excisionnecessary in benign papillary lesions initially diagnosed atcore biopsy? Breast. 2008;17:258262.

120. Rizzo M, Lund MJ, Oprea G, et al. Surgical follow-up andclinical presentation of 142 breast papillary lesions diagnosedby ultrasound-guided core-needle biopsy. Ann Surg Oncol.2008;15:10401047.

121. Tseng HS, Chen YL, Chen ST, et al. The management ofpapillary lesion of the breast by core needle biopsy. Eur JSurg Oncol. 2009;35:2124.

122. Bernik SF, Troob S, Ying BL, et al. Papillary lesions of thebreast diagnosed by core needle biopsy: 71 cases with surgical

follow-up.Am J Surg. 2009;197:473478.123. Sydnor MK, Wilson JD, Hijaz TA, et al. Underestimation of

the presence of breast carcinoma in papillary lesions initiallydiagnosed at core-needle biopsy. Radiology. 2007;242:5862.

124. Brenner RJ, Jackman RJ, Parker SH, et al. Percutaneous coreneedle biopsy of radial scars of the breast: when is excisionnecessary? AJR Am J Roentgenol. 2002;179:11791184.

125. Brodie C, ODoherty A, Quinn C. Fourteen-gauge needlecore biopsy of mammographically evident radial scars: isexcision necessary? Cancer. 2004;100:652663; author reply653-4.

126. Cawson JN, Malara F, Kavanagh A, et al. Fourteen-gaugeneedle core biopsy of mammographically evident radial scars:is excision necessary? Cancer. 2003;97:345351.

127. Douglas-Jones AG, Denson JL, Cox AC, et al. Radial scar

lesions of the breast diagnosed by needle core biopsy: analysisof cases containing occult malignancy. J Clin Pathol. 2007;60:295298.

128. Doyle EM, Banville N, Quinn CM, et al. Radial scars/com-plex sclerosing lesions and malignancy in a screeningprogramme: incidence and histological features revisited.Histopathology. 2007;50:607614.

129. Kirwan SE, Denton ER, Nash RM, et al. Multiple 14Gstereotactic core biopsies in the diagnosis of mammographi-cally detected stellate lesions of the breast. Clin Radiol.2000;55:763766.

130. Philpotts LE, Shaheen NA, Jain KS, et al. Uncommon high-risk lesions of the breast diagnosed at stereotactic core-needlebiopsy: clinical importance. Radiology. 2000;216:831837.

131. Sloane JP, Mayers MM. Carcinoma and atypical hyperplasiain radial scars and complex sclerosing lesions: importance of

lesion size and patient age. Histopathology. 1993;23:225231.132. Resetkova E, Edelweiss M, Albarracin CT, et al. Manage-

ment of radial sclerosing lesions of the breast diagnosed using




13/13

percutaneous vacuum-assisted core needle biopsy: recommen-dations for excision based on seven years of experience at asingle institution.Breast Cancer Res Treat. 2008. Jul 15, e-pub.

133. Becker L, Trop I, David J, et al. Management of radial scarsfound at percutaneous breast biopsy. Can Assoc Radiol J.2006;57:7278.

134. Jacobs TW, Chen YY, Guinee DG Jr, et al. Fibroepithelial

lesions with cellular stroma on breast core needle biopsy: arethere predictors of outcome on surgical excision? Am J ClinPathol. 2005;124:342354.

135. Lee AH, Hodi Z, Ellis IO, et al. Histological features useful inthe distinction of phyllodes tumour and fibroadenoma on needlecore biopsy of the breast. Histopathology.2007;51:336344.

136. Dershaw DD, Morris EA, Liberman L, et al. Nondiagnosticstereotaxic core breast biopsy: results of rebiopsy. Radiology.1996;198:323325.

137. Ioffe OB, Berg WA, Silverberg SG, et al. Mammographic-histopathologic correlation of large-core needle biopsies ofthe breast. Mod Pathol. 1998;11:721727.

138. Meyer JE, Smith DN, Lester SC, et al. Large-needle core biopsy:nonmalignant breast abnormalities evaluated with surgicalexcision or repeat core biopsy. Radiology. 1998;206:717720.

139. Komenaka IK, El-Tamer M, Pile-Spellman E, et al.Core needle biopsy as a diagnostic tool to differentiatephyllodes tumor from fibroadenoma. Arch Surg. 2003;138:987990.

140. Dupont WD, Page DL, Parl FF, et al. Long-term risk ofbreast cancer in women with fibroadenoma. N Engl J Med.1994;331:1015.

141. Rosen PP. Breast Pathology. 3rd ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2009:522.

142. Ro JY, Sneige N, Sahin AA, et al. Mucocele-like tumor of thebreast associated with atypical ductal hyperplasia or muci-nous carcinoma. A clinicopathologic study of seven cases.Arch Pathol Lab Med. 1991;115:137140.

143. Carder PJ, Murphy CE, Liston JC. Surgical excision iswarranted following a core biopsy diagnosis of mucocoele-like lesion of the breast. Histopathology. 2004;45:148154.

144. Renshaw AA. Can mucinous lesions of the breast be reliablydiagnosed by core needle biopsy? Am J Clin Pathol.2002;118:8284.

145. Gadre SA, Perkins GH, Sahin AA, et al. Neovascularizationin mucinous ductal carcinoma in situ suggests an alternativepathway for invasion. Histopathology. 2008;53:545553.



update on percutaneous needle biopsy

Documents