Commentary—Surgeon Performed Vacuum Assisted Breast Biopsy/Excision Is a Viable Paradigm for the Management of Benign and B3 Lesions—An Australian Multicenter Experience

Breast lesion management, notably that of indeterminate lesions, remains an evolving topic in the field of clinical oncology. The fundamental objectives of such management include diagnostic efficacy and complete excision, with more recent emphasis being put on precision and providing minimally invasive care. Vacuum-assisted biopsies (VAB) and vacuum-assisted excisions (VAE), once solely known as diagnostic tools, have become increasingly used in the management of B3 breast lesions (lesions defined by their uncertain malignant potential) offering a less invasive and potential alternative to open surgical excision [1]. Contributing to this field, Poels et al. conducted an Australian multicenter study examining the clinical outcomes and experiences of surgeon-performed ultrasound (US) guided VAB and VAEs [2]. The study included 137 diagnostic VABs and 325 VAE procedures, for a total of 397 patients who presented with radiologically benign and/or indeterminate breast lesions [2], providing a cohort size, that is, comparable to those of related sudies [1]. B3 lesions have been historically managed by surgical excision due to the concern of potential upgrade. A growing collection of literature is focusing on understanding upgrade rates of these lesions, aiming to guide management strategies that minimize possible surgical overtreatment [1, 3]. Many B3 lesions, aside from certain high-risk lesions associated with atypia, are predominantly being treated by VAE in the United Kingdom and other European countries, thus rendering a patient suitable for follow-up surveillance if complete removal of the lesion is confirmed in postprocedural imaging [1, 3]. Aligning with these trends, Poels et al. found that when excision was intended, a short-term follow-up US revealed complete removal of the breast lesion in 95% of cases, a high rate of complete excision [2]. For the majority of their patients, further follow-up US examination took place at 6–12 months, whereas few were followed for years [2]. This resulted in no further evidence of the previously excised lesion, supporting the use of VAE as a therapeutic tool in suitable cases of B3 lesions. This VAE success rate supported by an absence of lesion recurrence, may have been partly influenced by a low number of long-term follow-up cases. Given that previous studies have suggested a 5-year follow-up for surgically excised B3 lesions due to the increased risk of subsequent breast cancer development, extended and consistent follow-up postVAE should be a priority in future studies [3]. This would not only monitor the risk for delayed malignancy but also ensure that long-term VAE oncological safety is equivalent to surgical intervention in management of these high-risk lesions. A unique aspect of this study is the shift from radiologist-performed to surgeon-performed US-guided VABs and VAEs. The authors demonstrate the ability of breast surgeons, with the appropriate training, to perform successful VAB and VAE procedures, aiming to reduce preoperative radiologist support and generate more efficient patient care [2]. Although many breast surgeons have experience with US equipment and needle procedures, few have adequate training in diagnostic or interventional radiology to ensure complete lesion removal through US or stereotactic imaging modalities. Comprehensive training, available to physicians and implemented in surgical fellowship programs, would be required for the adoption of surgeon-performed VABs and VAEs in various healthcare systems [4]. Alternatively, an opposing argument has been made for the use of radiologist-performed VAEs on indeterminate breast lesions so as to alleviate a portion of breast surgeons' workloads and to reduce the demand of strained surgical resources [4]. Although both courses of action aim to streamline patientcare, the most experienced and qualified professional should ultimately be performing the procedures. To progress toward this management paradigm, multidisciplinary team discussions should determine the management of indeterminate breast lesions, involving the input of radiologists, pathologists, and surgeons. Additionally, the use of a postprocedural patient survey found 91% of respondents recorded their pain as none to mild during VAB or VAE, and 89% reported they would again undergo US-guided procedures over traditional surgical excision [2]. This positive reflection of patient satisfaction underscores a role for minimally invasive techniques that match the efficacy of more established surgical options. These findings also support the expanding use of patient-reported outcomes and patient-centered decision-making across oncological breast care [5]. Interestingly, patient-reported outcomes are most often reported in breast oncology studies [5], likely due to specific concerns surrounding body image and sexual well-being observed with breast cancer management. It is also important to acknowledge the potential selection bias in this study that may have positively impacted survey responses as only patients who chose to undergo these US-guided interventions were included. Moreover, the absence of comparative multivariate analyses invites confounding variables and limits the general applicability of these results. Accordingly, future randomized controlled studies on the management of indeterminate lesions should include adjusted analyses to compare patient-reported outcomes between VAE and conventional surgical excision as well as between VAB and traditional core needle biopsy. In conclusion, the use of VAB and VAE as minimally invasive options should be considered in the modern management of indeterminate breast lesions, provided that ongoing research continues to support their oncological safety. The successful implementation of these image guided techniques relies on access to the appropriate training for qualified professionals along with strong clinical judgment and multidisciplinary collaboration. In this context, Poels et al. present a range of various B3 lesions having undergone VAB and/or VAE conducted by three well-trained Australian breast surgeons. This, along with follow-up and a high response-rate to their patient satisfaction survey, provide additional evidence for the safe adoption of these techniques in outpatient clinics [2]. Vanessa Josey: conceptualization, writing – original draft, writing – review and editing. Silma Solorzano: conceptualization. Sarkis Meterissian: conceptualization, writing – review and editing. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.

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