Clinical Practice Guidelines for Ultrasound-Guided Breast Lesions and Lymph Nodes Biopsy: Chinese Society of Breast Surgery (CSBrS) Practice Guidelines 2021
Introduction
The field of breast surgery has witnessed significant advancements in image-guided biopsy techniques, particularly ultrasound-guided biopsy, which has become a cornerstone in the diagnosis of breast lesions and regional lymph nodes. The Chinese Society of Breast Surgery (CSBrS) has developed the 2021 Clinical Practice Guidelines for Ultrasound-Guided Breast Lesions and Lymph Nodes Biopsy to standardize these procedures and provide a reference for breast surgeons in China. These guidelines are based on the 2019 Consensus Statements and Operation Guidelines, updated with the latest evidence and clinical considerations.
Level of Evidence and Recommendation Strength
The guidelines employ the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence and the strength of recommendations. A total of 79 experts, including breast surgeons, oncologists, radiologists, pathologists, radiation therapists, and epidemiologists, formed the Recommendation Strength Review Committee to evaluate and vote on the recommendations.
Indications for Ultrasound-Guided Biopsy
The guidelines outline specific indications for ultrasound-guided biopsy of breast lesions and regional lymph nodes. For breast lesions, the primary indication is a Breast Imaging Reporting and Data System (BI-RADS) category of 4 or higher, which suggests a higher likelihood of malignancy. BI-RADS category 3 lesions with a family history of breast cancer or other high-risk factors are also recommended for biopsy. Additionally, biopsies are indicated for lesions being considered for neoadjuvant therapy or benign lesions requiring further pathological classification. For regional lymph nodes, biopsy is recommended when imaging suggests abnormal histomorphology or structure, with a suspicion of metastasis.
Methods for Breast Lesion Biopsy
The guidelines discuss three primary methods for breast lesion biopsy: fine-needle aspiration biopsy (FNAB), core needle biopsy (CNB), and vacuum-assisted breast biopsy (VABB). FNAB, while convenient, is limited by its inability to provide histopathological information and is not recommended as a first-line method. CNB, which collects tissue samples for histopathological diagnosis, is highly sensitive and provides reliable information on hormone receptor status. VABB, which allows for the removal of larger tissue samples, is particularly useful for diagnosing high-risk lesions and reducing the risk of underestimation.
Methods for Regional Lymph Node Biopsy
For regional lymph node biopsy, FNAB and CNB are the primary methods. FNAB, although commonly used, is limited by its cytological nature and inability to provide detailed histopathological information. CNB, on the other hand, offers higher diagnostic accuracy and is recommended for its ability to provide tissue samples for immunohistochemical evaluation.
Clinical Issues on Breast Lesion Biopsy
The guidelines address several clinical issues related to breast lesion biopsy, including the choice of needle size for CNB. Needles of 14G, 16G, and 18G are discussed, with 14G and 16G needles recommended for their diagnostic accuracy. The guidelines also emphasize the importance of obtaining at least four specimens during CNB to improve the diagnostic rate. Additionally, the guidelines highlight the risk of pathological underestimation in certain lesions, such as papilloma, atypical ductal hyperplasia (ADH), phyllodes tumor, radial sclerosing lesion, and carcinoma in situ, and recommend subsequent surgical resection for definitive diagnosis.
Contraindications and Relative Contraindications
The guidelines outline general contraindications for ultrasound-guided biopsy, including severe systemic diseases, mental disorders, inability to cooperate, and severe bleeding or coagulation disorders. Relative contraindications include lesions adjacent to prostheses and those with macro-calcification, which should be approached with caution.
Discussion
The guidelines emphasize the importance of selecting the appropriate biopsy method based on the clinical context and the limitations of each technique. While FNAB is convenient, its diagnostic limitations make it less suitable for first-line use in breast lesion biopsy. CNB and VABB are preferred for their ability to provide histopathological information and higher diagnostic accuracy. The guidelines also stress the importance of considering the risk of pathological underestimation in certain lesions and the need for subsequent surgical resection in these cases.
For regional lymph node biopsy, CNB is recommended over FNAB due to its higher diagnostic accuracy and ability to provide tissue samples for immunohistochemical evaluation. The guidelines also highlight the need for careful consideration of the anatomical location of lymph nodes, particularly those adjacent to blood vessels and nerves, to minimize the risk of secondary injuries.
Conclusion
The 2021 Clinical Practice Guidelines for Ultrasound-Guided Breast Lesions and Lymph Nodes Biopsy provide a comprehensive framework for the diagnosis and management of breast lesions and regional lymph nodes in China. By standardizing the indications, methods, and clinical considerations for ultrasound-guided biopsy, these guidelines aim to improve diagnostic accuracy and patient outcomes. Clinicians are encouraged to apply these guidelines in their practice while considering individual patient factors and the limitations of each biopsy technique.
doi.org/10.1097/CM9.0000000000001549
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