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Journal of Breast Cancer ISSN 1738-6756 J Breast Cancer 2008; March 11 (1): 30-5 ORIGINAL ARTICLE 유방의유두상종양진단에있어서초음파유도 14 게이지중심부바늘생검의유용성 정나영 1 ㆍ이재희 1,2 ㆍ이아원 3 ㆍ송병주 4 ㆍ정상설 4 가톨릭대학교의과대학 1 방사선과학교실, 2 휴먼영상의학센터, 가톨릭대학교의과대학 3 병리과학교실 4 외과학교실 Is US-guided 14-gauge Core Needle Biopsy Valid for Papillary Neoplasm of the Breast? Na Young Jung 1, Jaehee Lee 1,2, A Won Lee 3, Byung Joo Song 4, Sang Seol Jung 4 Department of 1 Radiology, The Catholic University of Korea, College of Medicine, Seoul; 2 Human Medical Imaging and Intervention Center, Seoul; Departments of 3 Pathology and 4 Surgery, The Catholic University of Korea, College of Medicine, Seoul, Korea Purpose: We wanted to determine the underestimation rate of ultrasound (US)-guided 14-gauge core needle biopsy for papillary neoplasms that were treated with subsequent surgical excision or vacuum-assisted biopsy (VAB) and we also wanted to evaluate the sonographic findings of papillary neoplasms. Methods: A retrospective review of the US-guided core needle biopsies of 984 consecutive lesions from January 2004 to April 2006 revealed 29 (3%) papillary neoplasms. Twenty five lesions were further excised by surgery (n=16) or VAB (n=9). The remaining 4 lesions were not further excised and they were excluded from this study. We evaluated the concordance between results of core needle biopsy and the final pathologic results. We reevaluate the sonographic findings of the papillary neoplasms included in our study. Results: The pathologic results of core needle biopsy were benign in 21 and atypical in four. Of the 21 benign papillomas, none were revealed as carcinoma after further excision. Just one lesion showed focal atypical ductal hyperplasia () after VAB. Three intraductal papillomas with underwent surgical excision (n=3) or VAB (n=1), and they were proved to be the same pathologic entities with (n=1) or without (n=3) lobular neoplasia. The sonographic findings were as follows: four intraductal masses, four intracystic masses, four solid masses with peripheral anechoic rims, five extraductal masses adjacent to dilated ducts, six pure solid masses, and two mixed masses. Conclusion: US-guide 14-gauge core needle biopsy for papillary neoplasm showed no underestimation after surgical excision or VAB in our study, and the procedure proved to be reliable for the assessment of papillary neoplasm if the imaging and pathologic findings were concordant. Papillary neoplasms showed variable sonographic findings. Key Words : Breast, Papilloma, Ultrasound-guided core needle biopsy, Automated gun biopsy 중심단어 : 유방, 유두종, 초음파유도중심부바늘생검, 자동총생검 서 론 책임저자 : 이재희 137-902 서울시서초구잠원동 12-25 K타워 3층, 휴먼영상의학센터 Tel: 02-512-6695, Fax: 02-512-6646 E-mail : jheerad@gmail.com 접수일 : 2007년9월 12일게재승인일 : 2007년12월17일 *2006년제62 차대한영상의학회학술대회구연발표되었음. *Scientific exhibition at 11th Congress of the World Federation for Ultrasound in Medicine and Biology (WFUMB), 2006 유방의유두상종양은유두종 (papilloma), 유두종증 (papillomatosis), 경화유두종 (sclerosing papilloma), 비정형유두종 (atypical papilloma), 유두상관내암종 (intraductal papillary carcinoma), 그리고유두상침습암종 (invasive papillary carcinoma) 를포함하는넓은범주의질환군이다.(1) 초음파유도중심부바늘생검은비교적시술이쉽고비침습적으로유방병변을 30

Is US-guided 14-gauge Core Needle Biopsy Valid for Papillary Neoplasm of the Breast? 31 진단할수있어널리이용되는생검방법이다. 그러나초음파유도중심부바늘생검으로얻은조각난 (fragmented) 제한적인표본으로유두상종양을진단하고양성과악성유두상종양을감별하는것은매우어려울수있다.(2, 3) 특히비정형성이동반된유두상종양을가진환자는양성유두상종양을가진환자보다상대적인암위험률이 7.5 배높으며, 주로병변이있는유방, 특히원래의유두상종양의인접부위에서암이발생하므로비정형성이동반된유두상종양은전구병변 (precursor lesion) 의가능성이높은것으로알려져있다.(4) 이러한비정형성이동반된유두상종양은중심부바늘생검으로저평가 (underestimation) 될가능성이 30% 내외로높기때문에수술적절제를해야하는것으로보고되고있다.(3, 5-11) 그에비하여양성유두상종양은저평가율이 0-26% 정도로다양하게보고되어추가치료에대한논란의여지가있다.(3, 5-10, 12-14) 본연구의목적은유방유두상종양에대한초음파유도 14 게이지중심부바늘생검후수술적절제또는진공흡인생검법 (vacuumassisted biopsy) 을받은경우의중심부바늘생검의저평가율을알아보고, 초음파유도중심부바늘생검으로진단받은유두상종양의초음파소견을평가해보고자하는것이다. 방법 2004년 1월에서 2006년 4월까지 984건의연속된유방병변에대한초음파유도 14 게이지중심부바늘생검에서 29 개 (2.9%) 의유두상종양이진단되었다. 이중 16 개의병변은수술적절제로, 9개의병변은초음파유도진공흡인생검법을통하여제거되었다. 나머지 4개의병변은더이상의절제를시행하지않아본연구에서제외되었다. 초음파유도중심부바늘생검과진공흡인생검법은환자에게시술의방법과합병증을설명하고동의서를받은후시행하였다. 모든중심부바늘생검은환자가똑바로또는비스듬하게누운상태에서초음파유도하에 12-5 MHz의고해상도선형탐촉자 (HDI 5000 Sono CT [Philips medical systems, Bothell, Washington, USA] and HDI 5000 ATL [Advanced Technology Laboratory, Bothell, Washington, USA]) 를이용하여시행되었으며, 14 게이지반자동중심부생검바늘 (TSK Laboratory, Tokyo, Japan) 을사용하여적어도 4회이상의조직표본을얻었다. 초음파유도진공흡인생검법은환자가똑바로또는비스듬하게누운상태에서 12-5 MHz 선형탐촉자로검사하면서, 진공흡인조직검사기구 (Mammotome; Ethicon-Endosurgery, Cincinnati, Ohio, USA) 를이용하여 11 게이지 (n=6) 혹은 8 게이지 (n=3) 바늘을이용하여초음파로보이는범위의병변을최대한제거하였다. 중심부바늘생검의결과와이후수술적절제또는초음파유도진공흡인생검법을통해얻은최종병리결과를한명의병리과의사가조직슬라이드를후향적으로검토하여재진단하였다. 각각의중심부바늘생검의결과와최종병리결과를비교분석하였다. 조직학적저평가 (histologic underestimation) 는중심부바늘생검결과는양성또는비정형유관증식증이었으나수술에서암이나온경우또는중심부바늘생검결과는관내암종이나왔으나수술에서침습암종으로나온경우로정의하였다.(15) 연구에포함된 25 명의환자들의의무기록을후향적으로검토하였다. 환자들의나이는 17-79세로평균 45세였다. 25명의환자중 13 명은증상이있었는데, 혈성유두분비물이있었던경우와장액성유두분비물이있었던경우가각각 3명과 2명이었고, 종괴가만져지는경우가 6명, 종괴와함께유두분비물이있었던경우가 2명이었다. 각환자의초음파판독지에기술된 American College of Radiology Breast Imaging-Reporting and Data System (ACR BI-RADS ) (16) 에의한최종판정카테고리를알아보았다. 카테고리 1은병변이없는경우, 카테고리 2는악성소견이없는경우, 카테고리 3은악성의가능성이희박한양성의증의경우, 카테고리 4는악성의가능성이있어조직검사가필요한경우, 카테고리 5는거의확실한악성의경우라는정의에따랐다. 카테고리 4는악성가능성의정도에따라 4A, 4B, 4C로구분하였다. 또한초음파영상을두명의방사선과의사가합의에의해후향적으로검토하여유두상종양들의크기, 위치, 경계, 유관확장증의동반여부, 방향그리고에코음영에대해분석하였다. 각유방종괴들을종괴와유관사이의관계에따라 Han 등 (17) 이보고한여섯가지부류로분류하였다 ; 이들은각각관강내 (intraluminal) 종괴, 늘어난유관근처에접해있는유관외 (extraductal) 종괴, 단순고형종괴, 그리고혼합형병변이다. 관강내종괴는유관의늘어난정도와종괴가관을채우고있는정도에따라유관내 (intraductal) 종괴, 낭종내 (intracystic) 종괴, 주변부무에코의띠를갖는고형종괴의세부류로분류되었다. 초음파유도하중심부바늘생검을시행하기전에유방촬영 (Mammography; Mammomat 3000, Seimens, Solna, Sweden) 을시행한환자의경우에는유방촬영사진을재검토하였다. 결과중심부바늘생검의병리결과는 21 예 (84%) 에서양성이었고, 4 예 (16%) 에서비정형성이었다. 양성결과로는유관내유두종이 14 예 (56%) 이고상용유관증식증 (usual ductal hyperplasia, ) 을동반한유관내유두종이 7예 (28%) 였으며, 4예 (16%) 의비정형

32 Na Young Jung, et al. 성결과는모두비정형성유관증식증 (atypical ductal hyperplasia, ) 을동반한유관내유두종이었다. 중심부바늘생검의결과와수술또는진공흡인생검법후최종병리조직결과를 Table 1에비교정리하였다. 21예의양성유두종중 1예에서진공흡인생검법후비정형성유관증식증이추가로발견되었을뿐수술 (n=13) 이나진공흡인생검법 (n=8) 후악성으로진단된경우는없었다. 4예의비정형성유관증식증을동반한유두종들은수술 (n=3) 또는진공흡인생검법 (n=1) 후모두같은진단명을가진병변으로확인되었고, 수술을했던환자중한명에서소엽성신생물 (lobular neoplasia) 를동반한것으로진단되었다. 이는유방의침습암종의위험인자일뿐악성은아니므로중심부바늘생검에서조직학적으로저평가된병변으로분류되지는않는다. 따라서본연구에서는중심부바늘생검시수술이나진공흡인생검법과비교하여조직학적저평가를보였던증례는없었다. 25 명의환자중 21 명이수술또는진공흡인생검후평균 20.2개월 (7-37개월 ) 의추적유방초음파검사를시행받았고이들중새로운병변이발견된환자는없었다. 본연구에포함된병변들의판독지를검토한결과 BI-RADS 카테고리는카테고리 3 (n=2), 4A (n=19) 또는 4B (n=4) 로대다수가양성가능성이높거나다소의심스러운소견이지만악성가능성은낮은병변으로보였다 (Table 2). 병변의평균크기는 1.1 cm이었고 (0.4-2.3 cm), 병변의위치는 12 예에서중심성, 13 예에서말초성이었다. 병변은 16 예에서분명한경계를보였고 9예에서는불분명한경계를보였으며, 종괴로보였던경우중 2예를제외하고는모두피부와평행한방향을보였다. 유관확장은 14 예에서동반되었다. 병변들은다양한에코음영을보였는데, 저에코성이 14 예, 등에코성이 7예, 혼합된에코음영을보인경우가 4예였다. 초음파소견으로병변들을 6가지범주로나누었는데, 유관내종괴가 4예, 낭종내종괴가 4예, 주변부무에코의띠를갖는고형종괴가 4예, 늘어난유관근처에접해있는유관외종괴가 5예, 단순고형종괴가 6예, 그리고혼합형이 2예였다 (Fig 1). 중심부바늘생검에서비정형성유관증식증을동반한 4예의유두종은각각유관내종괴, 낭종내종괴, 늘어난유관근처에접해있는유관외종괴, 단순고형종괴로다양하게보였다. 이중유관내종괴로보였던 1예에서수술후소엽성 Table 1. Histologic correlation between core needle biopsy and further excision Histologic findings at core needle biopsy Histologic findings at surgical excision with with with Histologic findings at VAB 9 1 0 0 2 1 1* 0 14 with 0 3 0 0 0 4 0 0 7 with 0 0 2 1* 0 0 1 0 4 Total 9 4 2 1 2 5 2 0 25 VAB=vacuum-assisted biopsy; =intraductal papilloma; =usual ductal hyperplasia; =atypical ductal hyperplasia; =lobular neoplasia. *Corrected pathology after surgical excision or VAB. with with with Total Table 2. Correlation between sonographic BI-RADS categories and histologic findings at surgical excision or VAB BI-RADS category N Histologic findings at surgical excision or VAB with with with C3 2 2 C4A 19 7 7 4 (1*) 1* C4B 4 2 2 Total 25 11 9 4 1 BI-RADS=Breast imaging reporting and data system; VAB=vacuumassisted biopsy; C3=BI-RADS category 3, probably benign; C4A=BI- RADS category 4A, suspicious abnormality with low suspicion of malignancy; C4B=BI-RADS category 4B, suspicious abnormality with intermediate concern; =intraductal papilloma; =usual ductal hyperplasia; =atypical ductal hyperplasia; =lobular neoplasia. *Corrected pathology after surgical excision or VAB. Table 3. Correlation between sonographic features and histologic findings at surgical excision or VAB Category (N=25) N Histologic findings at surgical excision or VAB with with with Intraductal 4 2 1 1* Intracystic 4 2 2 (1*) Solid with 4 1 3 anechoic rim Extraductal 5 2 2 1 Pure solid 6 4 1 1 Mixed 2 2 Total 25 11 9 4 1 VAB=vacuum-assisted biopsy; =intraductal papilloma; =usual ductal hyperplasia; =atypical ductal hyperplasia; =lobular neoplasia. *Corrected pathology after surgical excision or VAB.

Is US-guided 14-gauge Core Needle Biopsy Valid for Papillary Neoplasm of the Breast? 33 신생물이추가로발견되었다 (Fig 2). 중심부바늘생검에서양성유두종으로나왔던 21 예의종괴들은다양한초음파소견을보였으며, 그이후시행한조직절제술에서낭종내종괴로보였던 1예에서비정형성유관증식증이추가로발견된것 (Fig 3) 이외에는모두양성유두종으로확진되었다. 유두상종양의초음파소견에따른최종조직학적결과를 Table 3에정리하였다. 25 명의환자중 15 명에서수술전유방촬영술사진을얻을수 있었는데, 정상소견이 6예, 종괴가보였던경우가 6예, 비대칭음영이 1예, 매우치밀한조직을보여초음파검사를권유했던경우가 2예였으며, 미세석회화를동반한경우는없었다. 그러나연구에포함된환자중 60% (15/25) 에서만유방촬영필름을얻을수있었으며, 나머지환자들은타병원에서시행한필름을얻을수없었거나환자가젊은나이여서촬영하지않은경우로평가가불가능하였다. A B C D E F Fig 1. US categories of papillary neoplasms of breast. (A) Intraductal mass (n=4). (B) Intracystic mass (n=4). (C) Solid mass with peripheral anechoic rim (n=4). (D) Extraductal mass adjacent to the dilated duct (n=5). (E) Pure solid mass (n=6). (F) Mixed type (Intraductal+ Extraductal masses) (n=2). Fig 2. A 48-yr-old woman without specific symptom. US of left outer subareolar region shows mild ductectasia with an isoechoic intraductal lesion (arrows). Histopathology of core needle biopsy revealed an intraductal papilloma with atypical ductal hyperplasia. The lesion was surgically excised and confirmed as the same pathologic entity on core biopsy specimen with lobular neoplasia. Fig 3. A 79-yr-old woman with a palpable breast mass. US of left mid upper breast reveals an about 1.7 cm-sized circumscribed oval cyst with an internal nodular isoechoic solid portion (arrow). With core needle biopsy of the solid portion, the lesion was revealed as a benign papilloma. After 11 gauge VAB, the lesion was confirmed as papilloma with atypical ductal hyperplasia.

34 Na Young Jung, et al. 고찰유방의유두상종양은넓은범주를포함하는질환군으로초음파유도중심부바늘생검으로유두상종양을진단하고양성과악성유두상종양으로감별하는것은매우어렵다. 특히비정형성이동반된유두상종양은전암성병변으로여겨지며 30% 에달하는높은저평가율때문에수술적으로절제되어야하는병변으로잘알려져있다.(3, 5-11) 그러나중심부바늘생검에서양성유두상종양으로진단된경우에는저평가율이 0-26% 로다양하게보고되고있다.(3, 5-10, 12-14) 이전의여러연구들 (3, 5, 7-9, 13) 에서입체정위 (stereotactic directional) 또는초음파유도중심부바늘생검으로진단된양성유두상종양은절제후대부분양성으로판명되거나장기추적검사에서변화가없어영상소견과조직소견이일치한다면중심부바늘생검은양성유두상종양의진단에정확하여즉각적인수술적절제는필요하지않으나, 양성생검결과를보이더라도영상소견과병리소견이일치하지않는경우에는절제가시행되어야한다고기술하였다. 그러나최근몇몇연구들에서는중심부바늘생검에서진단된양성유두상종양도높은저평가율때문에수술적으로절제되어야하며, 모든유두상종양은관내암종또는침습암종의배제를위해모두조직검사를시행하는것이바람직하다고주장하였다.(6, 10, 12, 14) 이중 Mercado 등 (6) 이보고한관내암종으로상향진단된유두상종양들은 BI- RADS 카테고리 5의병변이거나고연령환자에서새로이발견된의심스러운미세석회화병변으로영상소견과중심부바늘생검결과간의불일치로바로수술적절제를했던경우이다. 한편 Liberman 등 (10) 은경피적유방생검으로양성유두종으로진단된영상-병리일치를보였던 35 예의증례의추적검사 ( 평균 22 개월 ) 중 5예의악성병변 (4 예의상피내암과 1예의임파선전이가없는 1.8 cm의침습암종 ) 과 6예의고위험병변이발견되었다고보고하였다. 악성증례중 1예는입체정위진공흡인생검법후임상의와환자의요구에의해 1개월이내수술을시행했던경우였고, 나머지는초음파유도중심부바늘생검후 7-25개월추적검사기간중종괴가증가되거나증상이나타나수술을시행했던경우였다. Lam 등 (12) 도중심부바늘생검으로양성유두종으로진단받았으며영상 -병리일치를보였던 7예중 1예에서수술후악성으로진단된경우가있어모든유두상종양은수술을하는것이좋다고주장하였다. 그러나이연구에서는 16 게이지의바늘로세번의중심부바늘생검표본만을얻었으므로 14 게이지바늘로네번이상의조직을얻었던우리의연구보다좀더검사의정확도가떨어질수있을것으로보인다. 이상의연구결과에서초음파유도중심부바늘생검에서양성이고영상-병리일치를보이더라도충분하고주의깊은추적검사가필요함을알수있다. 그러나본연구 에서는평균 20.2개월 (7-37개월 ) 의추적검사동안새로운병변이발견된경우는없었다. 또한본연구에서는초음파유도 14 게이지중심부바늘생검에서양성또는비정형성유두상종양으로진단된환자중수술적절제나초음파유도진공흡인생검법으로악성으로진단된경우는없었다. 이전연구의결과와달리비정형성유관증식증을동반한경우에도조직학적저평가를보인예가없었던것은연구에포함된병변의수가적으며포함된병변중의심스러운미세석회화를포함하는병변이없었고초음파에서도대부분악성가능성이비교적낮은 BI-RADS 카테고리 4B 이하의소견을보여영상 - 병리일치로생각되었던것과관계가있을것으로생각된다. 한편진공흡인생검법은 14 게이지중심부바늘생검에비해비교적많은조직을제거하므로저평가율이낮으나 (18), 수술적절제에비하여서는유두상종양을저평가할수있다.(6, 7, 10, 19) Mercado 등 (6) 은입체정위진공흡인생검법으로유두상관내암종으로진단받은 8예의병변중 2예 (25%) 가수술후침습암종으로진단되었으며 1예가진공흡인생검법으로양성유두종으로진단되었다가수술후유두상관내암종으로상향진단되었음을보고하였다.(19) 또한, Rosen 등 (7) 의연구에서는 11 게이지진공흡인생검법으로진단받은 8예의비정형성유두상종양중 2예가수술후유두상관내암종으로상향진단되었다고보고하였다.(7) Liberman의최근연구 (10) 에서도입체정위진공흡인생검법후양성유두종으로진단받았던증례에서영상 -병리일치를보였음에도불구하고 1개월이내의수술에서관내암종이동반되었음을확인한바있다. 위논문들에서상향진단된증례들은모두의심스러운석회화또는석회화를동반한종괴로보였던것에비해본연구에포함된중심부바늘생검후진공흡인생검법으로추가로병변을절제한 9예의증례중에서의심스러운석회화를포함하는병변은없었다. 이들 9예의유두상종양중중심부바늘생검에서비정형성유관증식증이동반되어있었던 2예를포함하여모든경우에서진공흡인생검법후추가로관내암종또는침습암종이발견된경우는없었으며, 모두영상소견과병리소견이일치하므로병변제거후추적검사를시행중이다. 추적기간 (5-28개월 ) 중새롭게생긴병변은아직발견되지않았다. 연구에포함된 25 예의유두상종양중 19 예에서초음파에서유관과의관계를시사할만한소견을동반하고있었다. 증례의수가많지않아통계적분석은어려우나비정형성을동반하거나하지않은유두상종양은각각다양한위치에다양한모양으로보였고비정형성을시사할만한초음파소견은발견되지않았다. 고전적으로중심성유두상종양보다말초성유방종양에서악성의확률이높다고알려져있으나, 근래의연구들에서는종양의위치, 개수, 모양보다는비정형성유관증식증을동반하였는가하는점이

Is US-guided 14-gauge Core Needle Biopsy Valid for Papillary Neoplasm of the Breast? 35 악성의확률과더관계가있다고보고하였다.(3, 4) 본연구의한계는초음파유도중심부바늘생검으로진단된유두상종양의증례수가적다는점과아직충분한추적검사가이루어지지않았다는점이다. 중심부바늘생검의유용성과결과를증명하기위해서는좀더많은수의증례와더긴기간의추적검사를통한추가연구가필요할것이다. 결론초음파유도 14 게이지중심부바늘생검은영상-병리일치 (Image-pathology concordance) 를보이는양성유두상종양의평가에대해서는믿을만한검사법이며, 양성과비정형성유두상종양은각각다양한초음파소견을보일수있다. 참고문헌 1. Tavassoli FA. Papillary lesions. In: Tavassoli FA, ed. Pathology of the breast. Norwalk Conn: Appleton & Lange; 1992;193-227. 2. Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant lesions in breast core needle biopsies: to excise or not to excise? Am J Surg Pathol 2002;26:1095-110. 3. Ivan D, Selinko V, Sahin AA, Sneige N, Middleton LP. Accuracy of core needle biopsy diagnosis in assessing papillary breast lesions: histologic predictors of malignancy. Mod Pathol 2004;17:165-71. 4. Page DL, Salhany KE, Jensen RA, Dupont WD. Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma. Cancer 1996;78:258-66. 5. Liberman L, Bracero N, Vuolo MA, Dershaw DD, Morris EA, Abramson AF, et al. Percutaneous large-core biopsy of papillary breast lesions. AJR Am J Roentgenol 1999;172:331-7. 6. Mercado CL, Hamele-Bena D, Oken SM, Singer CI, Cangiarella J. Papillary lesions of the breast at percutaneous core-needle biopsy. Radiology 2006;238:801-8. 7. Rosen EL, Bentley RC, Baker JA, Soo MS. Imaging-guided core needle biopsy of papillary lesions of the breast. AJR Am J Roentgenol 2002;179:1185-92. 8. Agoff SN, Lawton TJ. Papillary lesions of the breast with and without atypical ductal hyperplasia: can we accurately predict benign behavior from core needle biopsy? Am J Clin Pathol 2004;122:440-3. 9. Ko ES, Cho N, Cha JH, Park JS, Kim SM, Moon WK. Sonographically-guided 14-gauge core needle biopsy for papillary lesions of the breast. Korean J Radiol 2007;8:206-11. 10. Liberman L, Tornos C, Huzjan R, Bartella L, Morris EA, Dershaw DD. Is surgical excision warranted after benign, concordant diagnosis of papilloma at percutaneous breast biopsy? AJR Am J Roentgenol 2006;186:1328-34. 11. Lim JY, Oh SM. Usufulness of ultrasound guided core needle biopsy of breast lesions with automated gun. J Korean Breast Cancer Soc 1998;1:186-91. 12. Lam WW, Chu WC, Tang AP, Tse G, Ma TK. Role of radiologic features in the management of papillary lesions of the breast. AJR Am J Roentgenol 2006;186:1322-27. 13. Philpotts LE, Shaheen NA, Jain KS, Carter D, Lee CH. Uncommon high-risk lesions of the breast diagnosed at stereotactic core-needle biopsy: clinical importance. Radiology 2000;216:831-7. 14. Puglisi F, Zuiani C, Bazzocchi M, Valent F, Aprile G, Pertoldi B, et al. Role of mammography, ultrasound and large core biopsy in the diagnostic evaluation of papillary breast lesions. Oncology 2003;65: 311-5. 15. Burbank F. Stereotactic breast biopsy of atypical ductal hyperplasia and ductal carcinoma in situ lesions: improved accuracy with directional, vacuum- assisted biopsy. Radiology 1997;202:843-7. 16. American College of Radiology. Breast imaging reporting and data system (BI-RADS). 4th ed. Reston, VA: 2003. 17. Han BK, Choe YH, Ko YH, Yang JH, Nam SJ. Benign papillary lesions of the breast: sonographic-pathologic correlation. J Ultrasound Med 1999;18:217-23. 18. Ko ES, Cho N, Yang SK, Kim DY, Moon WK. Papillary lesions of the breast: Comparison of the US-guided 14-gauge automated gun method and the 11-gause directional vacuum-assisted biopsy method. J Korean Radiol Soc 2006;54:537-41. 19. Mercado CL, Hamele-Bena D, Singer C, Koenigsberg T, Pile-Spellman E, Higgins H, et al. Papillary lesions of the breast: evaluation with stereotactic directional vacuum-assisted biopsy. Radiology 2001;221:650-5.

36 Na Young Jung, et al.