Ultrasound-Guided Vacuum-Assisted Breast Biopsy for Breast Intraductal Lesions: a Meta-Analysis of Underestimation and Pathological Nipple Discharge Cure Rates US-guided VAB Bx for intraductal lesions

Parya Valizadeh (1), Payam Jannatdoust (2), Shirin Shahsavarhaghighi (3), Maedeh Rouzbahani (4), Mohammad Hossein Golezar (5), Nahid Sadighi (6)
(1) School of Medicine, Tehran University of Medical Science, Tehran, Iran, Iran, Islamic Republic of,
(2) School of Medicine, Tehran University of Medical Science, Tehran, Iran, Iran, Islamic Republic of,
(3) Tehran University of Medical Sciences, Tehran, Iran, Iran, Islamic Republic of,
(4) Tehran University of Medical Sciences, Tehran, Iran, Iran, Islamic Republic of,
(5) Tehran University of Medical Sciences, Tehran, Iran, Iran, Islamic Republic of,
(6) Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran, Iran, Islamic Republic of


Background: Breast intraductal lesions present a diagnostic challenge due to the diverse spectrum of histologic changes. Vacuum-assisted biopsy (VAB) has evolved as a pivotal diagnostic and therapeutic modality. Yet, concerns about the underestimation of malignancy using VAB persist. This review examines the underestimation rates of Ultrasound-guided VAB (US-VAB) for intraductal lesions and evaluates the effectiveness of VAB in addressing pathological nipple discharge (PND).

Methods: Following PRISMA guidelines, a comprehensive search was performed across Scopus, PubMed, and Web of Science. Studies detailing the underestimation rates of intraductal breast lesions diagnosed by US-VAB and cure rates for PND post-VAB excision were selected. Statistical analysis comprised a random effects proportion meta-analysis.

Results: In this research, 31 studies were deemed eligible: 26 for underestimation and 5 for PND cure rates post-US-VAB. Quantitative synthesis focused on studies reporting data on atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS) due to limited availability for other pathologies. The pooled underestimation rate for ADH was 6.14% (95% CI: 1.59%-12.43%). The pooled underestimation rate for DCIS was 13.26% (95% CI: 6.69%-21.08%). PND's pooled cure rate post-US-VAB was 93.32% (95% CI: 82.34%-99.70%).

Conclusion: This systematic review and meta-analysis show that US-VAB delivers low ADH underestimation rates, moderate DCIS underestimation rates, and acceptable PND cure rates in breast intraductal lesions.

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Alonso‐Bartolomé P, Vega‐Bolívar A, Torres‐Tabanera M, Ortega E, Acebal‐Blanco M, Garijo‐Ayensa F, et al. Sonographically guided 11‐g directional vacuum‐assisted breast biopsy as an alternative to surgical excision: utility and cost study in probably benign lesions. Acta radiol. 2004 Jul 30;45(4):390–6. doi: 10.1080/02841850410005633.

Houssami N, Ciatto S, Ellis I, Ambrogetti D. Underestimation of malignancy of breast core-needle biopsy. Cancer. 2007 Feb 1;109(3):487–95. doi: 10.1002/cncr.22435.

Page DL, Dupont WD, Rogers LW, Rados MS. Atypical hyperplastic lesions of the female breast. A long-term follow-up study. Cancer. 1985 Jun 1;55(11):2698–708. doi:10.1002/1097-0142(19850601)55:11%3C2698::AID-CNCR2820551127%3E3.0.CO;2-A

Dupont WD, Page DL. Risk Factors for Breast Cancer in Women with Proliferative Breast Disease. N Engl J Med. 1985 Jan 17;312(3):146–51. doi: abs/10.1056/NEJM198501173120303.

Rageth CJ, O’Flynn EAM, Pinker K, Kubik-Huch RA, Mundinger A, Decker T, et al. Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat. 2019 Apr 30;174(2):279–96. Available from: http://link.springer.com/10.1007/s10549-018-05071-1.

Sardanelli F, Trimboli RM, Tot T. Expert Review of Breast Pathology in Borderline Lesions. JAMA Oncol. 2018 Oct 1;4(10):1325. doi: 10.1001/jamaoncol.2018.1953.

Schiaffino S, Calabrese M, Melani EF, Trimboli RM, Cozzi A, Carbonaro LA, et al. Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions. Radiology. 2020;294(1):76–86. doi: 10.1148/radiol.2019190748.

Kuerer HM. Ductal carcinoma in situ : treatment or active surveillance? Expert Rev Anticancer Ther. 2015 Jul 3;15(7):777–85. doi: 10.1586/14737140.2015.1043897.

Dennis MA, Parker S, Kaske TI, Stavros AT, Camp J. Incidental Treatment of Nipple Discharge Caused by Benign Intraductal Papilloma Through Diagnostic Mammotome Biopsy. Am J Roentgenol. 2000 May;174(5):1263–8. doi: 10.2214/ajr.174.5.1741263.

Chang JM, Cho N, Moon WK, Park JS, Chung SY, Jang M. Does Ultrasound-Guided Directional Vacuum-Assisted Removal Help Eliminate Abnormal Nipple Discharge in Patients with Benign Intraductal Single Mass? Korean J Radiol. 2009;10(6):575. doi: 10.3348/kjr.2009.10.6.575.

Whiting PF. QUADAS-2: A Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies. Ann Intern Med. 2011 Oct 18;155(8):529. doi: 10.7326/0003-4819-155-8-201110180-00009.

Institute JB. JBI critical appraisal tool for cohort studies. 2020. Available from: https://jbi.global/critical-appraisal-tools

Higgins JPT. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60. doi: 10.1136/bmj.327.7414.557.

Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Heal. 2014 Dec 10;72(1):39. Available from: https://archpublichealth.biomedcentral.com/articles/10.1186/2049-3258-72-39

Furuya-Kanamori L, Barendregt JJ, Doi SAR. A new improved graphical and quantitative method for detecting bias in meta-analysis. Int J Evid Based Healthc. 2018 Dec;16(4):195–203. Available from: https://journals.lww.com/01787381-201812000-00003

Freeman MF, Tukey JW. Transformations Related to the Angular and the Square Root. Ann Math Stat. 1950 Dec;21(4):607–11. Available from: http://projecteuclid.org/euclid.aoms/1177729756

Furuya-Kanamori L, Doi SAR. LFK: Stata module to compute LFK index and Doi plot for detection of publication bias in meta-analysis. 2021. Available from: https://econpapers.repec.org/RePEc:boc:bocode:s458762

Lu W, Tu L, Xie D, Yao F, Lin L, Li Y, et al. A systematic review and meta-analysis: value of ultrasound-guided vacuum-assisted biopsy in the diagnosis and treatment of breast lesions. Gland Surg. 2021;10(10):3020–9. doi: 10.21037/gs-21-611.

Li X, Gao H, Xu M, Wu Y, Gao D. Breast papillary lesions diagnosed and treated using ultrasound-guided vacuum-assisted excision. BMC Surg. 20200915th ed. 2020;20(1):204.

Pijnappel RM, van den Donk M, Holland R, Mali WP, Peterse JL, Hendriks JH, et al. Diagnostic accuracy for different strategies of image-guided breast intervention in cases of nonpalpable breast lesions. Br J Cancer. 2004;90(3):595–600. doi: 10.1038/sj.bjc.6601559.

Huang XC, Hu XH, Wang XR, Zhou CX, Wang FF, Yang S, et al. A comparison of diagnostic performance of vacuum-assisted biopsy and core needle biopsy for breast microcalcification: a systematic review and meta-analysis. Ir J Med Sci. 20180316th ed. 2018;187(4):999–1008. doi: 10.1007/s11845-018-1781-6.

Yu YH, Liang C, Yuan XZ. Diagnostic value of vacuum-assisted breast biopsy for breast carcinoma: a meta-analysis and systematic review. Breast Cancer Res Treat. 20100204th ed. 2010;120(2):469–79. doi: 10.1007/s10549-010-0750-1.

Shen W, Sun Y, Song Y, Cui L, Jiang L. Learning curve in ultrasound-guided vacuum-assisted excision of breast lesions for surgeons and ultrasound physicians. Quant Imaging Med Surg. 20230208th ed. 2023;13(3):1478–87. doi: 10.21037/qims-22-573.

Suh YJ, Kim MJ, Kim EK, Moon HJ, Kwak JY, Koo HR, et al. Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy. Br J Radiol. 20120314th ed. 2012;85(1016):e349-56. doi: 10.1259/bjr/30974918.

Quinn-Laurin V, Hogue JC, Pinault S, Duchesne N. Vacuum-assisted complete excision of solid intraductal/intracystic masses and complex cysts: Is follow-up necessary? Breast. 20170622nd ed. 2017;35:42–7. doi: 10.1016/j.breast.2017.06.014.

March DE, Coughlin BF, Barham RB, Goulart RA, Klein S V, Bur ME, et al. Breast masses: removal of all US evidence during biopsy by using a handheld vacuum-assisted device-initial experience. Radiology. 20030403rd ed. 2003;227(2):549–55. doi: 10.1148/radiol.2272020476.

Brennan ME, Turner RM, Ciatto S, Marinovich ML, French JR, Macaskill P, et al. Ductal Carcinoma in Situ at Core-Needle Biopsy: Meta-Analysis of Underestimation and Predictors of Invasive Breast Cancer. Radiology. 2011 Jul;260(1):119–28. doi: 10.1148/radiol.11102368.

Ciatto S, Houssami N, Ambrogetti D, Bianchi S, Bonardi R, Brancato B, et al. Accuracy and Underestimation of Malignancy of Breast Core Needle Biopsy: the Florence Experience of Over 4000 Consecutive Biopsies. Breast Cancer Res Treat. 2007 Jan;101(3):291–7. doi: 10.1007/s10549-006-9289-6.

Badan GM, Roveda Júnior D, Piato S, Fleury E de FC, Campos MSD, Pecci CAF, et al. Diagnostic underestimation of atypical ductal hyperplasia and ductal carcinoma in situ at percutaneous core needle and vacuum-assisted biopsies of the breast in a Brazilian reference institution. Radiol Bras. 2016 Feb;49(1):6–11. doi: 10.1590/0100-3984.2014.0110.

Destounis S, Skolny MN, Morgan R, Arieno A, Murphy PF, Somerville P, et al. Rates of pathological underestimation for 9 and 12 gauge breast needle core biopsies at surgical excision. Breast Cancer. 2011 Jan;18(1):42–50. doi: 10.1007/s12282-010-0201-1.

Sydnor MK, Wilson JD, Hijaz TA, Massey HD, Shaw de Paredes ES. Underestimation of the Presence of Breast Carcinoma in Papillary Lesions Initially Diagnosed at Core-Needle Biopsy. Radiology. 2007 Jan;242(1):58–62. doi: 10.1148/radiol.2421031988.

Youk JH, Kim MJ, Son EJ, Kwak JY, Kim EK. US-guided vacuum-assisted percutaneous excision for management of benign papilloma without atypia diagnosed at US-guided 14-gauge core needle biopsy. Ann Surg Oncol. 20110824th ed. 2012;19(3):922–8. doi: 10.1245/s10434-011-2033-4.

Torres-Tabanera M, Alonso-Bartolomé P, Vega-Bolivar A, Sánchez-Gómez SM, Lag-Asturiano E, Sainz-Miranda M, et al. Percutaneous microductectomy with a directional vacuum-assisted system guided by ultrasonography for the treatment of breast discharge: experience in 63 cases. Acta Radiol. 2008;49(3):271–6. doi: 10.1080/02841850701769793.

Govindarajulu S, Narreddy SR, Shere MH, Ibrahim NB, Sahu AK, Cawthorn SJ. Sonographically guided mammotome excision of ducts in the diagnosis and management of single duct nipple discharge. Eur J Surg Oncol. 20060621st ed. 2006;32(7):725–8. doi: 10.1016/j.ejso.2006.05.006.

Ding B, Chen D, Li X, Zhang H, Zhao Y. Meta analysis of efficacy and safety between Mammotome vacuum-assisted breast biopsy and open excision for benign breast tumor. Gland Surg. 2013;2(2):69–79. doi: 10.3978/j.issn.2227-684X.2013.05.06.

Kim JH, Han K, Kim MJ, Moon HJ, Yoon JH, Park VY, et al. Atypical Ductal Hyperplasia on Ultrasonography-Guided Vacuum-Assisted Biopsy of the Breast: Considerations for Further Surgical Excision. Ultrasound Q. 2020;36(2):192–8. doi: 10.1097/RUQ.0000000000000478.


Parya Valizadeh
parya.valizadeh@gmail.com (Primary Contact)
Payam Jannatdoust
Shirin Shahsavarhaghighi
Maedeh Rouzbahani
Mohammad Hossein Golezar
Nahid Sadighi
Author Biography

Payam Jannatdoust, School of Medicine, Tehran University of Medical Science, Tehran, Iran

Payam Jannatdoust is a medical student at Tehran University of Medical Science, Tehran, Iran.

Valizadeh P, Jannatdoust P, Shahsavarhaghighi S, Rouzbahani M, Golezar MH, Sadighi N. Ultrasound-Guided Vacuum-Assisted Breast Biopsy for Breast Intraductal Lesions: a Meta-Analysis of Underestimation and Pathological Nipple Discharge Cure Rates: US-guided VAB Bx for intraductal lesions. Arch Breast Cancer [Internet]. 2024 Jan. 31 [cited 2024 Apr. 14];11(1):13-26. Available from: https://www.archbreastcancer.com/index.php/abc/article/view/846

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