Background Ductal carcinoma-in-situ (DCIS) is a growing health problem in the world. Before the advent of screening mammography, the incidence of DCIS was low, and patients presented with DCIS that had become clinically symptomatic. Upon this evidence, a strategy of aggressive surgical therapy like the approach with invasive cancer was adopted. The status of the regional lymph nodes is the most important prognostic factor and predictor of survival in breast cancer, but as DCIS is a malignant proliferation of the epithelial inside the breast duct and, therefore, does not have the capacity to generate metastasis. However, an upstaging after surgery is possible. The need for sentinel node biopsy (SNB) in patients with a preoperative biopsy diagnosis of DCIS is still controversial but is done in selected cases. Objectives Our main objective in this study was to evaluate the surgical approach in the axilla (SNB or axillary dissection – AD) of patients diagnosed with DCIS in a single institution and describe the surgical treatment (mastectomy or breast conservative surgery – BCS). In addition, we aimed to find the reasons that led our surgeons to choose one or the other treatment. Methods A retrospective analysis was made using the Pérola Byington Hospital’s database, from January 2011 to December 2019. During this period, 11,373 cases of breast cancer were treated int the institution and 812 (7.4%) were DCIS. Data was available and we could analyze 494 patients who underwent core biopsy or vacuum-guided biopsy guided by mammography or ultrasound and were diagnosed with DCIS and underwent surgical treatment at the Hospital. We grouped the patients into 3 age groups: under 40, 40-49, and 50 and over. In all groups, we had patients who underwent SNB using the patent blue technique or axillary dissection (AD) and were evaluated using the H&E method. We had also evaluated the type of surgery (BCS or mastectomy) in each age group. Results DCIS was diagnosed through mammographic alterations in 62% of all cases and nuclear grade 2 was the most common, with 47%, followed by grade 3 and 1, 46% and 4%, respectively. In 2% of cases the data was missing. Comedonecrosis was present in 78% of our specimens. The type of surgery (radical or BCS) was evaluated and BCS was made in 360 patients (72,87% of the cases), with the axillary approach being performed in 125 patients of these patients (50,20% of cases that went to axillary approach including 9 patients that were submitted to AD). In 27,1% the surgical approach was a radical surgery (total mastectomy or skin sparing mastectomy) and in this group 92,5% were submitted to axillary approach. There was a strong correlation in the type of surgery and axillary approach (p-value 0,000) In the group of patients younger than 40 years, 74% of patients (17 out of 23 in total) underwent an axillary approach regardless of the type of surgery (p-value 0.036) When evaluating the predetermined age groups, we saw that most of our patients were 50 years or more (69%), followed by patients between 40-49 years (26%) and 5% in patients under 40 years. In only 3% of cases (16 in 494) we reclassified the lesion as invasive carcinoma after the surgery. None of them had a lymph node involved by malignant cells after surgery and that’s include the cases reclassified as invasive carcinoma. Conclusion The results obtained in this analysis showing no axillary involvement will make us rethink the indications for the concomitant surgical approach of the breast and the axilla in cases with a diagnosis of DCIS to reduce the axillary surgical overtreatment. It was not our goal to compare the costs, mobility, and complications of the surgical treatment as the survival in these patients that can be addressed in another studies. Citation Format: Marcellus Ramos, Andre Mattar, Andressa Amorim, Felipe Cavagna, Mariana Passos, Raquel Fernandes, Jorge Shida, Luiz Henrique Gebrim. Is axillary evaluation still necessary in DCIS? [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-41.
Objectives: The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. However, an excisional biopsy inevitably makes a scar. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. More recently, image-guided percutaneous core-needle biopsy has become a frequently used method for diagnosing palpable and non-palpable breast lesions. Although sensitivity rates for core-needle biopsy are high, it has the disadvantage of histological underestimation, which renders the management of atypical ductal hyperplasia, papillary lesions, and fibroepithelial lesions somewhat difficult. Stereotactic vacuum assisted breast biopsy (VABB) was developed to overcome some of these negative aspects of core-needle biopsy. VABB allows for a sufficient specimen to be obtained with a single insertion and can provide a more accurate diagnosis and completely remove the lesion under real-time ultrasonic guidance. The advantage of complete lesion removal with VABB is to reduce or eliminate sampling error, to decrease the likelihood of a histological underestimation, to decrease imaging-histological discordance, to decrease the re-biopsy rate, and to diminish the likelihood of subsequent growth on follow-up, especially when stereotactic VABB is used to investigate microcalcifications. This method is expensive but cost effective when used to investigate microcalcifications classified as BI-RADS 4 and 5. Methodology: We performed a review in 1,354 patients with suspicious mammography microcalcifications, classified as BI-RADS 4 or 5 that were seen in Perola Byington Hospital from July 2012 to July 2017 in São Paulo-Brazil. We have used a Hologic Lorad Multicare Platinum Stereotactic Prone Breast Biopsy and a Surus Pearl (Hologic, Malbolrough, Massachusetts, USA), with gauge 9 probe. Four to eight fragments (median of 6) were obtained with the placement of a metal clip in the bed that the biopsy was performed, and histopathological analysis was made. Results: The histopathological study of the lesions revealed benign alterations in 956 (68%) of our patients. The findings were positive for malignancy in 358 patients (29%) and the precursor lesions were diagnosed in 40 (3%). In 81 cases (5.9%) the findings were discordant. The sensitivity of the method was 84.4%, specificity was 96.1%, false negative rate was 4.5%, positive predictive value (PPV) was 89.8%, negative predictive value (NPV) was 93.8%. In literature review the sensitivity varies 91.5-100%, specificity 81.9-110%, false negative rate 0-3.3%, PPV 92.2-100% and NPV 80.5-99.5%. All patients with positive or discordant cases underwent surgical treatment to increase the margin or complete removal of the lesion. Conclusions: The VABB is an outpatient procedure that avoids hospital admissions for diagnostic elucidation in most of cases suspected of malignancy. It has high predictive value in both benign and malignant lesions, guiding therapeutic planning. In addition to pre...
Background: Mammographic screening carried out in Brazil's Public Health System (SUS) is opportunistic and restricted to large cities mainly in the South and Southeast regions. However, only 30% of the suspicious calcifications are confirmed to be malignancy after the biopsy. The surgical procedure to investigate is still the routine in most centers in Brazil. A vacuum assisted stereotactic biopsy (VASB) is expensive and it is not available in most centers in the developing countries. Objective: To estimate saved values in SUS by performing VASB instead of performing classic surgical procedure in the investigation of suspicious calcifications. Methods: We’ve performed a retrospective and descriptive study from July, 2012 to June, 2019, in which 1,809 patients diagnosed with suspicious calcifications on mammography (BIRADS 4 and 5) had VASB performed at Hospital Estadual Pérola Byington. The device used was Surus Pearl (Hologic, Malbolrough, Massachusetts, USA) with probe gauge 9. The biopsy`s costs were calculated and estimated in terms of American Dollars (US$) in 2019. No direct medical and nonmedical or indirect costs have been evaluated. Results: the histopathological study of the lesions revealed benign alterations in 1,179 (65.1%) The findings were positive for malignancy in 533 (29.5%) and the precursor lesions were diagnosed in 97 (5.4%) VASB is an outpatient procedure; a single biopsy has an average cost of US$ 36. Instead, the classic surgical procedure is a procedure that requires hospitalization and general anesthesia with estimated cost of US$ 97 for every single procedure. The saved values in that time by SUS were US$ 29,077. Conclusion: we found a high economic impact of VASB in the SUS scenario. Lower costs than surgical procedures and being an outpatient procedure may indirectly increase hospital beds` supply for cancer treatment. Studies focusing on other direct and indirect costs are desirable, especially in developing countries. Keywords: calcifications; vacuum-assisted stereotactic biopsy; breast cancer. Citation Format: Andressa Amorim, Marcellus N. M. Ramos, Maria Isabela B. A. C. Sawada, André Mattar, Jorge Y. Shida, Luiz H. Gebrim. Stereotactic vaccum-assisted breast biopsy: A cost effective diagnostic method for suspicious calcifications investigation in Brazil [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-03-04.
Background: The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. However, an excisional biopsy inevitably makes a scar. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. Stereotactic vacuum assisted breast biopsy (VASB) can provide a more accurate diagnosis and completely remove the lesion under real-time ultrasonic guidance. The advantage of complete lesion removal with VASB is to reduce or eliminate sampling error, to decrease the likelihood of a histological underestimation, to decrease imaging-histological discordance, to decrease the re-biopsy rate, and to diminish the likelihood of subsequent growth on follow-up, especially when stereotactic VASB is used to investigate microcalcifications. This method is expensive but cost effective when used to investigate microcalcifications classified as BI-RADS 4 and 5. Objectives: To evaluate the accuracy of VASB in the investigation of suspicious calcifications. Methods: We’ve performed a retrospective study from July, 2012 to June, 2019, in which 1,809 women with suspicious calcifications detected on mammography (BI-RADS 4 and 5) had VASB performed at Hospital Estadual Pérola Byington, a public Hospital in São Paulo, Brazil. The device used was Surus Pearl (Hologic, Malbolrough, Massachusetts, USA), with probe gauge 9. Fragments were obtained and sent to anatomopathological study; a metal clip was placed on the biopsy site. Four groups were analyzed, based on the biopsy results: benign, precursor lesions, Ductal Carcinoma In Situ (DCIS) and malignant. Most patients with positive or discordant cases underwent surgical treatment and the previous biopsy results were compared to surgery results. Results: patients median age was 55y (49-63). Pathology results on VASB and surgery were classified respectively as benign n=1,179 (65.1%), precursor lesions n=97 (5.4%), DCIS n=414 (22.9%) and malignant n=119 (6.6%). Benign and lesion precursor lesions results were clustered to form a new group (lower risk lesions) and so DCIS and malignant lesions (higher risk lesions). ROC curve and AUC were calculated to compare the results of lower and higher risk lesions groups according to VASB and surgery results (AUC=0,642). The X2 test was performed between the groups (p<0,05). The sensitivity of the method was 84.4 %, specificity was 96.1%, false negative rate was 4.5%, positive predictive value (PPV) was 89.8%, negative predictive value (NPV) was 93.8%. Conclusion: the VASB method has a good accuracy to distinguish lower and higher risk lesions groups comparing to the gold standard. It has high predictive value in both benign and malignant lesions, guiding therapeutic planning. Keywords: Calcifications; Vacuum-assisted stereotactic biopsy; Breast cancer; Diagnosis Citation Format: Andressa Amorim, Marcellus N. M. Ramos, André Mattar, Maria Isabela B. A. C. Sawada, Jorge Y. Shida, Luiz H. Gebrim. Accuracy of stereotactic vacuum-assisted breast biopsy for investigating suspicious calcifications in 1,809 patients a public hospital in Brazil [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-03-03.
Introduction: The gold standard for breast biopsy procedures is currently an open excision of the suspected lesion. The cost and morbidity associated with this procedure has prompted many physicians to evaluate less invasive, alternative procedures. More recently, image-guided percutaneous coreneedle biopsy has become a frequently used method for diagnosing palpable and non-palpable breast lesions. Although sensitivity rates for core-needle biopsy are high, it has the disadvantage of histological underestimation. Vacuum-assisted stereotactic biopsy (VASB) was developed to overcome some of these negative aspects of core-needle biopsy. VASB allows for a sufficient specimen to be obtained with a single insertion and can provide a more accurate diagnosis and completely remove the lesion. Objectives: To evaluate the accuracy of vacuum-assisted stereotactic biopsy (VASB) in the investigation of non palpable suspicious calcifications. Methods: It was a retrospective study from July 2012 to December 2020, in which 2,021 women with suspicious calcifications detected on mammography (BI-RADS 4 and 5) had VASB performed at Hospital Estadual Pérola Byington, São Paulo, Brazil. The device used was Suros Pearl (Hologic, Malbolrough, Massachusetts, USA), with probe gauge 9. Fragments were obtained and sent to anatomopathological study; a metal clip was placed on the biopsy site. Four groups were analyzed, based on the biopsy results: benign, precursor lesions, Ductal Carcinoma In Situ (DCIS) and Invasive Ductal Carcinoma (IDC). Most patients with positive or discordant cases underwent surgical treatment and the previous biopsy results were compared to surgery results. Results: Patients´ median age was 55y (49–63y). Pathology results on VASB were classified respectively as benign n=1,340 (66.3%), precursor lesions n=84 (4.1%), DCIS n=441 (21.8%) and IDC n=156 (7.7%). Surgery was performed in the 60 patients with benign results on VASB, because of anatomopathological disagreement, with the following results: benign n=30 (50%), IDC e DCIS n=21 (35%) e precursor lesions n=9 (15%). ROC curve and AUC were calculated to compare the results of lower and higher risk lesions groups according to VASB and surgery results (AUC=0.79). The χ2 test was performed between the groups (p <0.05). The sensitivity of the method was 91.7 %, specificity was 97.1%, false negative rate was 3%, positive predictive value was 92.4%, negative predictive value was 96.9%. Conclusions: The VASB method has a good accuracy to distinguish lower from higher risk lesions groups comparing to the gold standard. It has high predictive value in both benign and malignant lesions, guiding therapeutic planning.
Introduction: Organized mammographic screening led to an increase in the diagnosis of DCIS. In countries with adequate mammographic coverage, the percentage of DCIS reaches 20%. In Brazi, most of the states only perform occasional mammographic screening, and data about DCIS incidence is scarce. Objectives: Analyze and describe clinical, diagnostic, imaging and therapeutic characteristics of patients diagnosed with DCIS and treated at Pérola Byington Hospital (PBH), Brazil. Methods: The official database of PBH from January 2011 to December 2019 showed 11,373 cases of breast cancer, and 812 (7.4%) of them were DCIS. We analyzed retrospectively the medical record of 332 patients who underwent biopsy, vaccum assisted biopsy guided by mammography or ultrasound whose diagnosis was DCIS, and they were treated at the hospital. Patients with previous breast cancer or lobular neoplasia were excluded. We divided the analysis into two groups, based on the type of surgery they underwent, conservative or radical surgery. Some patients have been submitted to the sentinel lymph node biopsy (SLNB) at surgery and the blue technique stained by H&E (hematoxylin and eosin) was used. Results: Most patients underwent conservative surgical treatment (73.5%), with a SLNB in 34.5%. Mastectomy was performed in 26.5% of cases and in this group 93.2% there was also axillary surgery. None of the sentinel nodes was involved. In the conservative surgery group, the mammographic alterations were the main cause for the diagnosis in 80.3% of the cases, with calcifications being the most common alteration in 73.9% of the cases, followed by the palpable lesion in 18.5% of them. Mammography was also the main diagnostic test in the group of patients who underwent mastectomy (73.9%) and calcifications appeared in 67% of cases, followed by palpable lesions in 28.1%. When assessing local recurrence, a percentage of 6.4% was found in conservative surgery (ten in situ and five invasive) and 4.5% in mastectomy (one in situ and four invasive). Conclusions: The 7.4% incidence of DCIS shows that even though lower than in countries that have organized screening, it is a growing demand, especially for the public health system where stereotactic biopsy is not available in many centers. Despite the fact that most of the cases were non palpable, we found that mastectomy was indicated in 23.5% of them, probably because of the extension and multicentricity of the DCIS. The absence of metastases in SNB made us rethink the real need for its indication.
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