Vacuum-assisted breast biopsy role in the differential diagnosis of mammary gland focal lesions
DOI: 10.32364/2587-6821-2024-8-6-1
A.V. Goncharov1,2, N.A. Cherninkaya3,4, E.N. Gavrilov5
1Far Eastern Federal University, Vladivostok, Russian Federation
2Mammological Center LLC, Vladivostok, Russian Federation
3Clinical Hospital "RZD-Meditsina" of the city of Vladivostok, Vladivostok, Russian Federation
4Pacific State Medical University, Vladivostok, Russian Federation
5Medical and Sanitary Unit of the Ministry of Internal Affairs of Russia in the Primorsky Territory, Vladivostok, Russian Federation
Aim: to determine the role of vacuum-assisted breast biopsy (VABB) in the differential diagnosis of focal pathology in the mammary glands.
Patients and Methods: 57 female patients aged 19 to 77 years (mean age 39.7±13.2 years) who sought medical help in the period from 2018 to March 2021 with complaints of palpable mass, were retrospectively studied for follow-up or screening. According to ultrasound, focal lesions with anechoic and/or hypoechoic pattern in the mammary glands were visualized in all female patients, and the BI-RADS 2–4 category was established. To clarify the diagnosis, the VABB procedure was performed by ultrasound control followed by morphological analysis. A total of 90 focal lesions have been studied.
Results: of the 90 studied focal lesions in the mammary glands diagnosed in 57 female patients, 86 lesions were benign (95.5%) after histopathology. Fibroadenoma was verified in 58.8% of focal lesions. In 41.5% of foci, it was combined with other benign changes, including increased risk. The malignant pattern of the lesion was diagnosed in 4 cases (4.5%), whereas according to the ultrasound, a malignant tumor was suspected and the BI-RADS 4C category was established in only 2 of them. Simple fibroadenoma (34.4%), sclerosing adenosis (8.9%) and atypical hyperplasia (1.1%), as well as their combination (24.4%) in ultrasound commonly do not have specific signs and in most cases are visualized as typical benign fibroadenomas, which complicates the differential diagnosis of these pathologies and determines the need for morphological verification.
Conclusion: according to the set of ultrasound signs, it can't be allowed to establish the pattern of focal lesion in detail. VABB under ultrasound control, being a minimally invasive technique, allows to obtain the best material for histology avoiding surgical intervention, and thereby demonstrates a higher accuracy level in the differential diagnosis of mammary gland focal lesions, and allows to eliminate the ultrasound drawbacks.
Keywords: vacuum-assisted breast biopsy, atypical hyperplasia, fibroadenoma, sclerosing adenosis, breast cancer, differential diagnosis.
For citation: Goncharov A.V., Cherninkaya N.A., Gavrilov E.N. Vacuum-assisted breast biopsy role in the differential diagnosis of mammary gland focal lesions. Russian Medical Inquiry. 2024;8(6):315–320 (in Russ.). DOI: 10.32364/2587-6821-2024-8-6-1.
Background
Given their high prevalence, breast diseases (including malignancies) represent an urgent public health concern on a global scale.
In the period between 2019 and 2021, breast cancer (BC) was the most prevalent cancer in Russia, accounting for 18.3% of all diagnosed cases in 2021 (1-3). In 2021, 72.5% of newly diagnosed BC cases were identified in stages I-II, while 27.1% were identified in stages III-IV. The increase in the proportion of cases identified at an early stage (from 65.0% to 72.5% over the past decade) highlights the importance of screening and diagnosis of precancerous conditions [1].
Digital mammography and ultrasound (US) remain the gold standard for the diagnosis of breast disease [4]. Ultrasonography is an invaluable diagnostic instrument for women over the age of 40, and it is also employed as an adjunctive modality in cases where clinical or mammographic findings are suspicious or equivocal. In addition to its diagnostic applications, US is also employed to direct invasive procedures.
In addition to facilitating the differential diagnosis of cysts and solid masses, the clear US criteria developed by the American College of Radiology (ACR) assist in characterizing focal breast lesions, thereby enhancing the clinical efficacy of this method. As demonstrated by existing research, the sensitivity and specificity of US in differentiating benign from malignant lesions are 95.95% and 91.42%, respectively [5].
While the differential diagnosis of BC is of paramount importance, benign tumors are also worthy of consideration, given their pervasive occurrence and potential for progression to malignancy [6-8].
However, the differential diagnosis of various histologic types of benign tumors is challenging due to the lack of a specific US appearance in the majority of cases. In the context of US imaging, the presumptive diagnosis of all focal masses with typical benign US findings is fibroadenoma. In accordance with the BI-RADS (Breast Imaging Reporting and Data System) ACR scale, BI-RADS categories 2 and 3 (corresponding to benign and probably benign pathology, respectively) have been established. Consequently, some authors advocate for the observation of these lesions as the recommended course of action [9, 10].
The elevated risk of malignant transformation in specific categories of benign tumors represents a significant concern, necessitating continuous monitoring and prompt intervention in the event of malignancy.
The aim of this study is to ascertain the role of vacuum-assisted biopsy (VAB) in the differential diagnosis of focal breast masses.
Patients and Methods
In the initial phase of this retrospective study, the results of 13,079 breast US examinations conducted between 2018 and 2021 were subjected to analysis. The results of each examination were evaluated according to the BI-RADS classification for breast imaging.
The study was conducted in accordance with the ethical standards and all study participants provided informed consent for the use of their data. In approximately 54.5% of cases (n=7124), the findings fell into categories 2 and 3. The findings classified as BI-RADS category 1 constituted less than half (n=5473, 41.8%) of all examinations performed. The frequency of BI-RADS categories 4-6 was significantly lower, with BI-RADS 4 detected in 2.24% (n=293), BI-RADS 5 in 1.13% (n=148), and BI-RADS 6 in 0.15% (n=19). Consequently, the prevalence of breast lesions diagnosed by US (BI-RADS 2-6 categories) was 58% (n=7586) across all studies during the specified period, with a preponderance of benign and likely benign lesions.
In the second phase, a group of women with focal breast lesions meeting the specified criteria was identified among all US examinations performed (n=13,079). The identified group consisted of women who met the following criteria:
- BI-RADS category 2-5;
- presence of single or multiple focal breast masses or areas of hypoechoic and/or anechoic structure (including those described as cysts);
- age 15 years and older.
The following criteria were used to exclude women from this group:
- age less than 15 years;
- pregnancy or lactation;
- hyperechoic masses only;
- lymphadenopathy of the axillary, supraclavicular, and subclavian lymph nodes, without focal breast masses.
The group selected for the second phase comprised 6,147 ultrasound findings. The frequency of hypoechoic and/or anechoic focal masses accounted for 81.3% (n=4997) of all pathologic breast lesions. The majority of cases (n=4069, 66.2%) were anechoic focal masses. In 940 (15.3%) cases, anechoic masses were associated with hypoechoic masses.
To ascertain the diagnostic significance of VAB in the differential diagnosis of focal breast masses in women with diagnosed hypoechoic and/or anechoic focal masses (6147 US examinations), a study group of 57 women aged 19-77 years (mean age 39.7±13.2 years) who had registered at the mammology center for a palpable mass, dynamic follow-up, or screening examination (a total of 73 US examinations were performed, 90 cases of focal masses were diagnosed) was assembled.
The study group was selected based on the presence of an established histologic diagnosis for which the specimen was obtained through VAB under US guidance, as indicated in the US reports.
All 57 women underwent VAB under US guidance for the histologic diagnosis of identified focal masses. A total of 90 procedures were conducted. In cases of high-probability benign tumors (BI-RADS categories 2-3 and 4a), VAB was employed not only for diagnostic purposes but also as a therapeutic alternative to surgery. In the case of high-probability malignant tumors (BI-RADS category 4c), VAB was employed exclusively for diagnostic purposes.
VAB under US guidance was performed in a unit equipped with an EnCorClassic™ Breast Biopsy System (BARD, Inc.) with 7G and 10G disposable probes (depending on the purpose of the study), a SonoSite 180 Plus Portable Ultrasound System (FUJIFILM SonoSite, Japan), and an operating table. The linear transducer was positioned over the mass throughout the procedure, and the resulting image was displayed on the screen for subsequent analysis.
The VAB technique allows for the acquisition of both the focal mass and a small quantity of surrounding tissue. In addition to confirming the diagnosis, this technique provides information about background changes in the breast that may have caused these focal masses.
The conclusions of the ultrasound scans with an established BI-RADS category were compared with the results of the histological examination. To evaluate the results of the study, statistical parameters were calculated using the standard Microsoft Office Excel 2016 package. This program was used to calculate the mean (M), standard deviation (σ), and arithmetic mean error for age and occurrence of various characteristics of focal masses in B-mode.
To assess the diagnostic efficacy of standard US (B-mode and Doppler color flow mapping), the parameters of informativeness, including sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV), were calculated. The reliability of quantitative differences between US signs of different types of benign masses was determined using a parametric Student's t-test for relative values, with a p-value of less than 0.05 generally accepted in medical research.
Results and Discussion
All 57 women were diagnosed with focal masses by US. In 20 (35.1%) of the women, the pathological process was multiple. In 15 of the 20 (26.3%) women, focal masses were identified in both mammary glands. The remaining 37 women (64.9%) exhibited a single focal mass.
The BI-RADS category was determined based on the totality of the US features observed in the focal masses. 20 women (35.1%) were assigned BI-RADS 2, 28 women (49.1%) were assigned BI-RADS 3, and 9 women (15.8%) were assigned BI-RADS 4. Consequently, the most prevalent category was BI-RADS 3, which was diagnosed in nearly half of the women. It is noteworthy that published data indicate that this proportion of all detected neoplasms is classified as BI-RADS 3. In the BI-RADS 4 category, 4a was diagnosed in 4 (7%) women and 4c in 2 (3.5%) women. The subcategory was not determined in 3 women (5.3%), and thus, due to the limited sample size, BI-RADS 4 was considered a single category encompassing women with suspected BC risk based on US findings.
Based on the ultrasound findings, the focal tumor was classified as benign in 48 women (84.2%) and as probably malignant (with a range of 2% to 95%) in 9 women (15.8%).
A total of 90 tumors were identified in all quadrants of the breast, as well as in the periareolar area. Approximately half of all pathological changes were observed in the upper outer quadrant (n=44, 48.9%), less frequently in the periareolar zone (n=24, 26.7%), and in the upper inner quadrant (n=12, 13.3%). The lowest incidence of pathology was observed in the lower quadrants, specifically the lower-internal (n=3, 3.3%) and lower-outer (n=7, 7.8%) regions.
Based on the ultrasound findings, the most probable diagnosis was fibroadenoma (FA) in 60 cases (66.7%), followed by cyst in 19 cases (21.1%), malignancy in 3 cases (3.3%), and 8 cases were undetermined. The group of undetermined masses included those with an undetermined nosology and lacking a combination of typical features.
All 57 women underwent US-guided VAB to establish the histologic diagnosis of the visualized focal masses (n=90). This diagnostic technique was selected as the most representative and accurate, as previously described in detail elsewhere (17, 18).
A total of 86 (95.5%) breast lesions were histopathologically determined to be benign, while 4 (4.5%) were identified as malignant. Benign breast lesions were classified as fibroadenoma (FA) (n=31, 34.4%), sclerosing adenosis/SA (n=8, 8.9%), or a combination of the two (n=20, 22.2%), or nodular mastopathy (n=13, 14.1%). The remaining cases were classified as follows: 4% were classified as atypical hyperplasia (AH), 1% were AH plus FA, 1% were AH plus FA and CA, and 5% were cysts. This distribution of morphologic variants is consistent with that observed in breast tumors.
The observed breast malignancies were infiltrating non-specific carcinoma (n=2, 2.3%), invasive ductal carcinoma (n=1, 1.1%), and infiltrating tubular carcinoma (n=1, 1.1%).
The most frequently encountered tumor in US examinations, fibroadenoma (66.7%), was identified in 53 (58.8%) of the histologic reports. In 22 cases (41.5% of all diagnosed FA cases), this focal mass was associated with other benign tumors, including SA, AH, and a combination of the two that was not identified in any US report.
Malignancies were identified in 4 cases, representing 4.4% of the total number of cases. In contrast, only 3 malignancies were suspected based on US findings. Conversely, 1 tumor initially identified as malignant by US was subsequently determined to be a SA based on its morphological characteristics.
The correlation between US and histologic findings is illustrated in the accompanying table.
SA was identified in 5 cases (62.5%) as an anechoic mass with well-defined, regular borders. Consequently, it was not possible to distinguish between SA and cysts, which exhibited comparable characteristics in 60% of cases. Consequently, in 4 cases of SA that were confirmed by US, the diagnosis was made as a cyst (in another case, the diagnosis was not specified).
The group exhibiting the greatest degree of histological heterogeneity was that of nodular mastopathy (n=13). The following histologic changes were identified: focal stromal hyperplasia, lobular hyperplasia, ductal hyperplasia, and sclerosing hyperplasia; tortuous and cystically dilated ducts; fibrosis; focal stromal proliferation; and focal apocrine epithelial metaplasia. On US , these changes exhibited typical features of simple FA, including a hypoechoic structure (n=9, 69.2%) with sharp, well-defined borders and regular shape (n=12, 92%) and a homogeneous structure (n=11, 84.6%). The observed differences in the rate of typical FA signs (hypoechoic mass with sharp, well-defined borders and regular shape) in FA alone and nodular mastopathy were not statistically significant (t=1.2, p>0.05).
Therefore, benign tumors lack distinctive characteristics across the various groups and are typically identified as FA in most cases. Conversely, SA exhibits cystic features in 50% of cases.
No pathological lesions were identified based on the results of two VABs. These cases illustrate the potential for a false-positive diagnosis of focal masses by US.
Four malignant neoplasms were identified by VAB in the course of this study, representing 4.4% of all cases. Conversely, US imaging indicated a high probability of malignancy in only two of the cases. The masses exhibited the following characteristics: hypoechoic structure, irregular well-defined borders, and irregular shape. In one case, perinodular blood flow was identified. The remaining two cases of malignancy were identified as typical benign tumors (hypoechoic masses with well-defined, regular borders and regular shape devoid of blood flow), thus classifying these masses as BI-RADS 2 (preliminary diagnosis: FA).
Therefore, the ultrasound appearance of benign tumors, irrespective of their classification, was predominantly characterized by the following features: a regular shape, well-defined borders, a homogeneous echo structure, and an absence of vascularity. Only a small percentage of benign tumors exhibited any of these characteristics. Therefore, the combination of FA and SA and the combination of FA and AH were more frequently characterized by an anechoic structure and irregular, well-defined borders than FA alone (0% and 9.7% vs. 13.6% and 22.7%, respectively), indicating a complex lesion. A solitary SA area exhibited the typical features of a cyst, thereby complicating the differential diagnosis. However, it was more prevalent than cysts with poorly defined irregular borders and irregular shape (12.5% vs. 0% for cysts). AH can be identified in 33.3% of cases by the presence of one of three features: poorly defined borders, irregular borders, or the presence of blood flow.
It is indisputable that breast diseases in women hold considerable social significance and represent a pivotal concern in contemporary society. The elevated prevalence of breast diseases in women is corroborated by the elevated diagnosis rate observed in the analysis of 13,076 US images. From 2018 to 2021, over half (58%) of all findings indicated the presence of breast disease.
In addition to the importance of the instrumental differential diagnosis of malignant and benign lesions, the difficulty lies in the differential diagnosis of different groups of benign lesions, which are of interest because of the risk of malignant transformation. The correct choice of treatment, given the possible negative consequences, is determined by the aforementioned risk.
According to the US study, 84% of the women examined were found to have benign tumors throughout the entire period (BI-RADS 2-3). The results of the morphological examination indicated that benign tumors were present in 95% of cases, thereby confirming their high prevalence.
In addition to the high prevalence of benign lesions in both age groups, attention is primarily directed towards them due to the potential risk of malignant transformation and the lack of differential diagnosis based on US results between high- and low-risk groups, largely due to the absence of specific US appearances.
At present, all typical benign tumors are diagnosed with a preliminary diagnosis of "fibroadenoma" based on ultrasound findings, which, according to numerous authors, does not necessitate morphological confirmation.
Fibroadenoma was diagnosed in 53 (58.8%) of the 90 focal masses. In 22 cases (41.5% of all diagnosed FA), the presence of other benign lesions not detected by US was identified. In 62.5% of cases, FA exhibited cyst-like characteristics (60%).
In the diagnosis and differential diagnosis of FA, the sensitivity of US was 96%, specificity 59%, accuracy 80%, positive predictive value 77%, and negative predictive value 91%.
The study revealed that, as the most prevalent benign focal mass, FA is frequently associated with high-risk conditions. A differential US diagnosis of complex conditions and solitary FA reveals that the differences between FA and its combination with SA and/or AH are not statistically significant (p > 0.05). Furthermore, the differences between the US signs of FA and nodular mastopathy were also statistically insignificant (p > 0.05), thereby confirming the difficulty of differential diagnosis of these diseases. Therefore, it is not possible to distinguish the combination of FA with intermediate and high-risk conditions in terms of their progression to malignancy based on US appearance, which is of particular significance in AH.
Conclusions
In light of these findings, it can be concluded that although US has high sensitivity, allowing for the identification of FA based on its distinctive features, it also has a high false-positive rate, low specificity, and no statistically significant difference in the US signs of FA alone and its combination with other benign tumors, nodular mastopathy. This indicates that US has limited efficacy in differentiating benign tumors. A diagnosis based on US alone, without morphological confirmation of the nature of the mass, is not possible. VAB provides the necessary level of accuracy in the differential diagnosis of focal breast masses and compensates for the shortcomings of ultrasonography.
About the authors:
Andrey V. Goncharov — Assistant Professor of the Department of Medical Biochemistry and Biophysics, Far Eastern Federal University; 10, Ajax, Russky Island, Vladivostok, 690922, Russian Federation; oncologist, Mammological Center LLC; 17v, Kalinina str., Vladivostok, 690077, Russian Federation; ORCID iD 0000-0001-9450-8996.
Natalia A. Cherninkaya — functional diagnostics physician, Clinical Hospital "RZD-Meditsina" of the city of Vladivostok; 25, Verkhneportovaya str., Vladivostok, 690003, Russian Federation; resident physician, Pacific State Medical University; 2, Ostryakova Ave., Vladivostok, 690002, Russian Federation; ORCID iD 0000-0002-1786-8696.
Eduard N. Gavrilov — functional diagnostics physician, Medical and Sanitary Unit of the Ministry of Internal Affairs of Russia in the Primorsky Territory; 44, Aleutskaya str., Vladivostok, 690091, Russian Federation; ORCID iD 0000-0003-0878-8720.
Contact information: Andrey V. Goncharov, e-mail: andrey-v-goncharov@yandex.ru.
Financial Disclosure: no authors have a financial or property interest in any material or method mentioned.
There is no conflict of interest.
Received 02.06.2024.
Revised 26.06.2024.
Accepted 19.07.2024.
2. Злокачественные новообразования в России в 2020 году (заболеваемость и смертность). Под ред. Каприна А.Д., Старинского В.В., Шахзадовой А.О. М.: МНИОИ им. П.А. Герцена — филиал ФГБУ «НМИЦ радиологии» Минздрава России; 2021.Malignant neoplasms in Russia in 2020 (morbidity and mortality). Kaprin A.D., Starinsky V.V., Shakhzadova A.O., eds. M.: MNIOI im. P.A. Gertsena — filial FGBU "NMITS radiologii" Minzdrava Rossii; 2021 (in Russ.).
3. Состояние онкологической помощи населению России в 2019 году. Под ред. Каприна А.Д., Старинского В.В., Шахзадовой А.О. М.: МНИОИ им. П.А. Герцена — филиал ФГБУ «НМИЦ радиологии» Минздрава России; 2020.The state of cancer care for the population of Russia in 2019. Kaprin A.D., Starinsky V.V., Shakhzadova A.O., eds. M.: MNIOI im. P.A. Gertsena — filial FGBU "NMITS radiologii" Minzdrava Rossii; 2020 (in Russ.).
4. Funke M. Bildgebende Diagnostik des Mammakarzinoms: Ein Update [Diagnostic imaging of breast cancer: An update]. Radiologe. 2016;56(10):921–938 (in German). DOI: 10.1007/s00117-016-0134-6.
5. Binnuhaid A.A., Alshoabi S.A., Alhazmi F.H. et al. Predictive value of ultrasound imaging in differentiating benign from malignant breast lesions taking biopsy results as the standard. J Family Med Prim Care. 2019;8(12):3971–3976. DOI: 10.4103/jfmpc.jfmpc_827_19.
6. Visscher D.W., Nassar A., Degnim A.C. et al. Sclerosing adenosis and risk of breast cancer. Breast Cancer Res Treat. 2014;144(1):205–212. DOI: 10.1007/s10549-014-2862-5.
7. Nassar A., Visscher D.W., Degnim A.C. et al. Complex fibroadenoma and breast cancer risk: a Mayo Clinic Benign Breast Disease Cohort Study. Breast Cancer Res Treat. 2015;153(2):397–405. DOI: 10.1007/s10549-015-3535-8.
8. Hartmann L.C., Degnim A.C., Santen R.J. et al. Atypical hyperplasia of the breast — risk assessment and management options. N Engl J Med. 2015;372(1):78–89. DOI: 10.1056/NEJMsr1407164.
9. Olarinoye-Akorede S.A., Yunusa G.H., Aliyu H., Hamidu A.U. Breast Imaging Reporting and Data Systems category 3 (probably benign) breast lesions detected on diagnostic breast ultrasound: The prevalence, outcome and malignancy detection rate in Zaria, Nigeria. SA J Radiol. 2018;22(2):1315. DOI: 10.4102/sajr.v22i2.1315.
10. Barr R.G., Zhang Z., Cormack J.B. et al. Probably benign lesions at screening breast US in a population with elevated risk: prevalence and rate of malignancy in the ACRIN 6666 trial. Radiology. 2013;269(3):701–712. DOI: 10.1148/radiol.13122829.
11. Гончаров А.В., Апанасевич В.И., Мордвинов Ю.П., Павлюк Ю.Г. Малоинвазивная хирургия молочной железы: тотальная вакуумная биопсия. Опухоли женской репродуктивной системы. 2017;13(1):20–24. DOI: 10.17650/1994-4098-2017-13-1-20-24.Goncharov A.V., Apanasevich V.I., Mordvinov Yu.P., Pavlyuk Yu.G. Minimally invasive breast surgery: vacuum-assisted core biopsy. Tumors of female reproductive system. 2017;13(1):20–24 (in Russ.). DOI: 10.17650/1994-4098-2017-13-1-20-24.
12. Левченко К.Ф., Баранов А.И. Вакуумная аспирационная биопсия: малоинвазивный метод лечения доброкачественной патологии молочных желез. Обзор литературы. Опухоли женской репродуктивной системы. 2018;14(2):36–41. DOI: 10.17650/1994-4098-2018-14-2-36-41.Levchenko K.F., Baranov A.I. Vacuum aspiration biopsy: a minimally invasive method for treating benign breast pathology. Literature review. Tumors of female reproductive system. 2018;14(2):36–41 (in Russ.). DOI: 10.17650/1994-4098-2018-14-2-36-41.
13. Рожкова Н.И., Кочетова Г.П., Мазо М.Л. Вакуумная аспирационная биопсия под рентгеновским и ультразвуковым контролем с диагностической и лечебной целью. В кн.: Материалы V Всерос. научно-практ. конф. «Организационные, медицинские и технические аспекты клинической маммологии». М.; 2007:143–149.Rozhkova N.I., Kochetova G.P., Mazo M.L. Vacuum aspiration biopsy under X-ray and ultrasound control for diagnostic and therapeutic purposes. In: Materials of the V All-Russian scientific and practical conference "Organizational, medical and technical aspects of clinical mammology". M.; 2007:143–149 (in Russ.).
14. Castells X., Domingo L., Corominas J.M. et al. Breast cancer risk after diagnosis by screening mammography of nonproliferative or proliferative benign breast disease: a study from a population-based screening program. Breast Cancer Res Treat. 2015;149(1):237–244. DOI: 10.1007/s10549-014-3208-z.
15. Hudson-Phillips S., Graham G., Cox K., Al Sarakbi W. Fibroadenoma: a guide for junior clinicians. Br J Hosp Med (Lond). 2022;83(10):1–9. DOI: 10.12968/hmed.2022.0070.
16. Nguyen D.L., Myers K.S., Oluyemi E. et al. BI-RADS 3 Assessment on MRI: A Lesion-Based Review for Breast Radiologists. J Breast Imaging. 2022;4(5):460–473. DOI: 10.1093/jbi/wbac032.
17. Cullinane C., Byrne J., Kelly L. et al. The positive predictive value of vacuum assisted biopsy (VAB) in predicting final histological diagnosis for breast lesions of uncertain malignancy (B3 lesions): A systematic review & meta-analysis. Eur J Surg Oncol. 2022;48(7):1464–1474. DOI: 10.1016/j.ejso.2022.04.005.
18. Yashima Y., Fujioka T., Kubota K. et al. Comparison of the clinical and pathological characteristics of ultrasound-guided biopsy for breast masses and non-mass lesions between 16-gauge spring-loaded core needle biopsy and 12-gauge spring-loaded vacuum-assisted biopsy. J Med Ultrason (2001). 2023;50(2):205–212. DOI: 10.1007/s10396-022-01279-3.
19. Bi J., Tang H., Lin X. et al. Morphological features of 52 cases of breast phyllodes tumours with local recurrence. Virchows Arch. 2022;481(4):519–531. DOI: 10.1007/s00428-022-03383-8.
20. Zhang M., Arjmandi F.K., Porembka J.H. et al. Imaging and Management of Fibroepithelial Lesions of the Breast: Radiologic-Pathologic Correlation. Radiographics. 2023;43(11):e230051. DOI: 10.1148/rg.230051.
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