Original article
The cost effectiveness of vacuum-assisted versus core-needle versus surgical biopsy of breast lesions
Estudio de costo-efectividad de la biopsia mamaria asistida por vacío versus biopsia con aguja gruesa o arpón
P. Fernández-Garcíaa,
, S.F. Marco-Doménecha,b, L. Lizán-Tudelac, M.V. Ibáñez-Guald, A. Navarro-Ballestera, E. Casanovas-Feliua
Corresponding author
a Servicio de Radiología Diagnóstica y Terapéutica, Hospital General Universitario de Castellón, Castellón, Spain
b Departamento de Medicina, Universidad Jaime I, Castellón, Spain
c Outcomes’10, Universidad Jaime I, Castellón, Spain
d Departamento de Matemáticas, IMAC, Universidad Jaime I, Castellón, Spain
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"apellidos" => "Lizán-Tudela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.V." "apellidos" => "Ibáñez-Gual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Navarro-Ballester" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "E." "apellidos" => "Casanovas-Feliu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Radiología Diagnóstica y Terapéutica, Hospital General Universitario de Castellón, Castellón, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universidad Jaime I, Castellón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Outcomes’10, Universidad Jaime I, Castellón, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Matemáticas, IMAC, Universidad Jaime I, Castellón, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio de costo-efectividad de la biopsia mamaria asistida por vacío <span class="elsevierStyleItalic">versus</span> biopsia con aguja gruesa o arpón" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Management of breast lesions has changed in the last few years when it comes to diagnosis and intervention techniques. At the beginning, the only possibility of obtaining an anatomopathological diagnosis of a breast lesion was harpoon-guided surgical biopsy. This modality has been gradually replaced by less invasive modalities, such as core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). VAB has a number of advantages with respect to CNB and surgical biopsy, since by obtaining larger-caliber samples it achieves a greater percentage of correct diagnoses in a minimally invasive way.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The goal of this paper is to conduct an economic study of the three types of breast biopsy that exist and identify which is the most cost-effective option.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This is an observational, retrospective, analytical study on the 997 breast biopsies of 804 lesions in 761 patients, performed in our unit between January 1st, 2011 and December 31st, 2014, without excluding any lesion. Mean age: 56.19<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>14.66 years; age range: 15–93 years. This study was evaluated and approved by the hospital ethics committee yet patients did not sign the written informed consent to be included in the study because of the retrospective nature of the study. All biopsies were conducted by two radiologists.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We divided these 997 breast biopsies in three groups based on the biopsy modality used. The first group included the biopsies conducted through vacuum aspiration using the 9-gauge ATEC 0912-20 machines (Hologic, Vilvoorde, Belgium). The second group included biopsies conducted using 14-gauge-10-centimeter long thick needles with the BARD MONOPTY automatic gun (Bard, Crawley, United Kingdom). The third group were surgical biopsies (Somatex Medical Technologies, Teltow, Germany). Two types of guides were used in all of them: ultrasound with Toshiba XARIO with PLT-805 AT 8<span class="elsevierStyleHsp" style=""></span>MHz linear probe (Toshiba Europe BV, Zoetermeer, The Netherlands) and vertical digital stereotaxy (STX) with mammography machine MAMMOMAT 3000 Nova Opdima R (Siemens, Tres Cantos, Spain).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The 804 lesions initially underwent 615 CNB, 173 VAB and in 16 cases a harpoon was placed immediately. In 19 cases it was recommended to repeat the percutaneous biopsy and in 174 cases to place a harpoon.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The 19 percutaneous biopsies that had to be repeated correspond to one VAB that had to be re-done and to 18 CNB, in which a new CNB had to be performed in 11 cases while in the remaining seven cases it was decided to conduct a VAB to complete the diagnosis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">At the end, the CNB group consisted of 626 biopsies, the VAB group of 181 biopsies and the surgical group of 190 biopsies.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Result variables</span><p id="par0040" class="elsevierStylePara elsevierViewall">Modality variables: we analyzed the type of breast biopsy and the guide used.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The anatomopathological result of the surgical piece was the reference standard, in such a way that the percentage of matches between the radiological biopsy and the surgical biopsy was at the same time the percentage of correct diagnoses obtained through CNB and VAB, respectively. Non-operated patients underwent control follow-up through mammograms or ultrasounds 6 and 12 months after the biopsy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Financial study</span><p id="par0050" class="elsevierStylePara elsevierViewall">We conducted a cost-effectiveness analysis of the aforementioned three (3) biopsy modalities by analyzing direct and indirect costs. We did not take intangible costs into consideration.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although it was a study conducted along the course of 4 years, we calculated the total costs of the different types of biopsy 2014 inflation-adjusted. When it comes to direct costs, the cost of fungible material based on data provided by our hospital financial management unit, plus the cost of each procedure in compliance with the Generalitat Valenciana Fee Regulation Act<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> was taken into account. This analysis did not include any device repayment costs or direct non-medical costs.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Cost estimates</span><p id="par0060" class="elsevierStylePara elsevierViewall">The total cost of each modality was the sum of adding direct and indirect costs.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Direct costs are the ones that resulted from the sum of the costs that a given procedure represented for each medical service involved (radiology and pathological anatomy in the case of radiologic biopsies and radiology, pathological anatomy and surgery in the case of surgical biopsies).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Indirect costs corresponded to loss of productivity (sick leave days) of each patient for undergoing this type of procedures. After the CNB, the patient was on sick leave on the day of the test (1 day), after a VAB, on the day of the test and the following day (2 days) and after delivery of a harpoon the sick leave mean duration was 12 days.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Since not all patients who underwent biopsies were of working age or active workers and regarding all patients beyond 16 years old and younger than 65 as active workers, we came up with a weighted mean of indirect costs for each biopsy modality based on whether the patients were active or passive.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In order to calculate indirect costs, data from the website of the National Statistics Institute – <span class="elsevierStyleItalic">INE in Spanish</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> were reviewed. Based on these data, we assumed that the mean annual salary for women in 2014 was €19,456.04; the result of the ratio between the mean annual salary and the 365 days of a calendar year was equal to the average money not earned each day by each patient because of undergoing a breast biopsy procedure – that is 53.30<span class="elsevierStyleHsp" style=""></span>€/day.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally, in order to know the total costs of each biopsy modality we added direct and indirect costs as applicable.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Effect estimate</span><p id="par0090" class="elsevierStylePara elsevierViewall">The effect that we wanted to measure was “percentage of cases diagnosed correctly” with each breast biopsy modality, in other words, the percentage of matches between radiological biopsies and surgical biopsies, and to that end we used the anatomopathological results of the different biopsies and surgery.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mean ratio estimate</span><p id="par0095" class="elsevierStylePara elsevierViewall">Once costs and effects for the different types of breast biopsy modalities were estimated, we related costs and effects through the mean ratios based on its formula (mean ratio<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>cost/effect). The numerator represented total costs of each biopsy modality and the denominator the effect achieved with each biopsy modality.</p><p id="par0100" class="elsevierStylePara elsevierViewall">With the mean ratio all the information is reduced to a common denominator that indicates what the cost of achieving one effect unit with each of the different biopsy modalities is; thus, the lowest mean ratio corresponds with the most cost-effective option and the option with the highest mean ratio with the least cost-effective one.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0105" class="elsevierStylePara elsevierViewall">The variables in this study were exported to the R program version 3.1.3. We performed a descriptive and inferential analysis. For the analysis of categorical (qualitative) variables, we used the <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test and to compare the quantitative variables, we used ANOVA or Student's <span class="elsevierStyleItalic">t</span> test, depending on the number of groups we wanted to compare. We considered as a statistically significant level a <span class="elsevierStyleItalic">P</span> value <0.05. In the inferential study, we analyzed the correlation between variables and one comparative study of the matches between the result of radiological biopsy and surgical biopsy.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">The VAB group consisted of 181 biopsies, 68 (37.6 per cent) through ultrasound guide and 113 (62.4 per cent) through STX guide. In the CNB group, 626 biopsies were conducted, 581 (92.8 per cent) through ultrasound guide and 45 (7.2 per cent) through STX guide. Of the 190 surgical biopsies, the ultrasound guide was used in 127 (66.8 per cent) and the vertical digital STX in 63 (33.2 per cent) of the cases.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the course of these 4 years, the percentage of each type of biopsy has remained relatively constant.</p><p id="par0120" class="elsevierStylePara elsevierViewall">When comparing the percentage of correct diagnoses obtained among the three modalities for breast lesions overall, no significant differences among them were reported: for harpoon biopsies it was 100 per cent, for CNB, 91.81 per cent, and for VAB, 94.03 per cent, with a <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.3485; there were no significant differences either when comparing CNB with VAB, with a <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.4944 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Nevertheless, when studying microcalcifications and nodules separately there were indeed significant differences in cases with microcalcifications; the percentage of matches was much higher for VAB (96.77 per cent) than for CNB (50 per cent), with a <span class="elsevierStyleItalic">P</span> value <0.0001. In the case of nodules these differences disappeared (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Nodules (73.13 per cent) and microcalcifications (14.68 per cent) were the most frequently biopsied lesions. Nodules were biopsied preferably through CNB (74.4 per cent), microcalcifications through VAB (54.8 per cent) and harpoon biopsies (31.33 per cent), with a <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Financial study. Cost estimate</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Direct costs from the unit of radiology:</span> costs from the unit of radiology for conducting a CNB, VAB or surgical biopsy based on the imaging guide used and taking into account that the cost of a CNB needle amounted to €19.96 and that of a VAB needle €351.60 can be seen in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The difference between the cost of STX-guided CNB (€211.03) and that of US-guided CNB (€140.84) reveals the savings (€70.19) that occurred whenever a radiologist would use ultrasound guidance instead of STX guidance to conduct these kinds of biopsies.</p><p id="par0140" class="elsevierStylePara elsevierViewall">When calculating the weighted average cost for each biopsy based on the imaging guidance used, the mean direct cost from the unit of radiology of a CNB amounted to €145.88, that of a VAB, €516.30, and that of a harpoon placement €193.46.</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Direct costs from the unit of pathological anatomy:</span> the anatomopathological study of the cylinders obtained through a CNB or VAB was considered a type 2 biopsy with a cost of €41.92. The study of the surgical piece obtained after the harpoon placement was considered a type 4 biopsy and its cost amounted to €109.47.</p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Direct costs from the surgical unit:</span> the placement of a harpoon was considered a major ambulatory surgery intervention with a cost of €968.77 according to the Valencian Fee Regulation Act.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Thus the direct costs of the CNB equalled the sum of the direct costs from the unit of radiology (€145.88) plus the direct costs from the unit of pathological anatomy (€41.92), for a total of €187.80.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The direct costs of the VAB equalled the sum of the direct costs from the unit of radiology (€516.30) plus the direct costs from the unit of pathological anatomy (€41.92), for a total of €558.22.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">direct costs</span> of the surgical biopsy equalled the sum of the direct costs from the unit of radiology (€193.46) plus the direct costs from the unit of pathological anatomy (€109.47) plus the direct costs from the surgical service (€968.77), that is €1271.70.</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Indirect costs</span>: indirect costs for the CNB amounted to €53.30 (one sick day), for the BAV the cost amounted to €106.60 (two sick days) and for the harpoon biopsy the cost amounted to €639.60 (12 sick days).</p><p id="par0175" class="elsevierStylePara elsevierViewall">When calculating the weighted means of indirect costs for each biopsy modality based on whether the patients were active or passive workers, the mean indirect cost of the CNB amounted to €37.29, that of the VAB amounted to €80.68 and that of the harpoon biopsy amounted to €508.31.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Thus, the total cost of the CNB amounted to €225.09, that of the VAB amounted to 638.90<span class="elsevierStyleHsp" style=""></span>€ and that of the harpoon biopsy amounted to €1780.01.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Effect estimate</span><p id="par0185" class="elsevierStylePara elsevierViewall">Making an overall assessment of breast lesions allowed us to confirm 461 lesions biopsied through CNB that were operated on, among these, there are 423 in which the diagnosis obtained from the CNB matched that of the surgery, that is, 91.81 per cent (423/461) of cases were diagnosed correctly. We had 134 lesions biopsied through the VAB that were operated on after the biopsy. Among these, the diagnosis obtained from the VAB matched the surgical diagnosis in 126, that is, 94.03 per cent (126/134) of cases were diagnosed correctly (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0190" class="elsevierStylePara elsevierViewall">But making a separate assessment of the lesions presenting as microcalcifications and nodules confirmed that the lesions occurring as microcalcifications that were biopsied through CNB, matched the surgical biopsy in 50 per cent (8/16) of the cases and those biopsied through VAB matched the surgical biopsy in 96.77 per cent (60/62) of the cases. The lesions presenting as nodules and biopsied through CNB matched the surgical biopsy in 94.44 per cent (374/396) of the cases and the nodules that were biopsied through VAB matched the surgical biopsy in 91.07 per cent (51/56) of the cases (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><p id="par0195" class="elsevierStylePara elsevierViewall">We see that there are no significant differences between the nodules biopsied through CNB and those biopsied through VAB, but there were indeed significant differences when it comes to microcalcifications. Those biopsied through VAB showed a percentage of matches with the surgical biopsy that was significantly greater than that of the microcalcifications biopsied through CNB.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Mean ratio estimate</span><p id="par0200" class="elsevierStylePara elsevierViewall">The mean ratio regardless of the type of lesion was 2.45 for the CNB, 6.79 for the VAB and 17.80 for harpoon biopsy.</p><p id="par0205" class="elsevierStylePara elsevierViewall">We calculated the mean ratio for biopsies of microcalcifications and nodules separately. In the case of microcalcifications, the mean ratio for the CNB was 4.50, for the VAB it was 6.60 and for harpoon biopsies it was 17.80. In the case of nodules, the mean ratio for the CNB was 2.38, for the VAB, 7.01 and harpoon biopsies it was 17.80.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Thus, both in the overall assessment of all the lesions and in the assessment of microcalcifications and nodules separately, the most effective and the most expensive option were harpoon biopsies, and the most cost-effective and consequently the dominant option was the CNB compared to the other modalities.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0215" class="elsevierStylePara elsevierViewall">Our study reveals that though the percentage of cases diagnosed correctly through CNB was 91.81 per cent versus 94.03 per cent of VAB and 100 per cent of surgical biopsy, there were no statistically significant differences in the percentage of correct diagnoses among the three biopsy modalities, with a <span class="elsevierStyleItalic">P</span> value of 0.3485.</p><p id="par0220" class="elsevierStylePara elsevierViewall">For us harpoon biopsies have a total cost of €1780.01, versus €638.90 of the total costs from the VAB and €225.09 of total costs from the CNB. Therefore in our study of cost-effectiveness, the mean ratio of harpoon biopsies was 17.80, that of VAB was 6.79 and that of CNB was 2.45, while if microcalcifications or nodules are calculated separately the relation of mean ratios stays the same; thus in our study the CNB is the most cost-effective modality and despite the fact that CNB is the modality that arrives to the least correct diagnoses of all (91.81 per cent), it is the one that arrives at each diagnosis at a better price making it the most cost-effective option of all.</p><p id="par0225" class="elsevierStylePara elsevierViewall">But economic studies are just one of the pillars upon which we should base our decisions on the evaluation of new technologies. There are other factors such as preferences, the patients’ expectations and medical-legal and ethical considerations that help us make decisions when it comes to using these modalities. Thus, when biopsying microcalcifications through CNB we only arrive at correct diagnoses in half the cases. If we take into account that what we are trying to do is rule out the presence of breast cancer, having a diagnostic modality that produces 50 per cent of errors does not seem acceptable. These results, therefore, advice against biopsying microcalcifications through CNB and it is preferred to conduct biopsy of such microcalcifications through VAB or harpoon biopsies.</p><p id="par0230" class="elsevierStylePara elsevierViewall">When comparing VAB and harpoon biopsies from the economic point of view, we can see that the VAB with 94.03 per cent of correct diagnoses and a total cost of €638.90 has a mean ratio of 6.79 while harpoon biopsies with 100 per cent accuracy and total costs of €1780.01 have a mean ratio of 17.80, so the VAB is more cost-effective than harpoon biopsies since it has a lower mean ratio. This is why the VAB is the most cost-effective option when compared to harpoon biopsies and it is the modality that should be used from the economic point of view when it comes to microcalcifications. Other authors agree on this matter too.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Harpoon-guided surgical biopsy has been the traditional procedure for diagnostic confirmation of breast lesions suspicious of malignancy<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> though over time, other modalities have been developed capable of providing accurate histologic diagnoses without the need for surgery.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Nevertheless, harpoon biopsies continue to be used in cases of radiopathological mismatch after a prior percutaneous biopsy.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Surgical excisional biopsy is considered the standard of use since it is highly effective though it is an expensive biopsy modality.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3,9</span></a> In time we have been able to see that the CNB could be an alternative to harpoon biopsies thanks both to its good results and because it is not expensive making it the most cost-effective option compared to the diagnostic harpoon biopsy<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10,11</span></a> – even compared to the VAB.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">All these reasons made CNB win over the harpoon biopsy as a modality of choice when diagnosing breast lesions.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> But the CNB has important disadvantages, above all in the case of microcalcifications, mainly due to errors while taking the sample and histological underestimation.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> VAB modalities appeared to solve these problems, obtaining a more abundant sample and reducing false negatives and clinical underestimations considerably.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15,16</span></a> The VAB is more effective than the CNB, but in this study, as well as in others,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> there are no significant differences between the percentage of correct diagnoses obtained among the harpoon biopsy, the CNB or the VAB.</p><p id="par0250" class="elsevierStylePara elsevierViewall">There are economic studies comparing CNB, VAB and harpoon biopsies.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3,5,11,17–19</span></a> In all of these cost-effectiveness studies, the harpoon biopsy is the least cost-effective modality since yet despite the fact that it has the highest percentage of correct diagnoses, it is the most expensive modality and has the highest mean ratio of all. Liberman et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> reported a 20 per cent cost reduction in VAB with a 11<span class="elsevierStyleHsp" style=""></span>G needle compared to harpoon biopsies since they considered that the VAB prevented surgery in 76 per cent of the lesions biopsied through VAB though we should bear in mind that this study only analyzed direct – not indirect medical costs ignoring any losses of productivity due to breast biopsies. We should bear in mind that the percentage of cases that avoided surgery (76 per cent) is very high compared to the study by Gruber et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> that showed that 29 per cent of their patients avoided surgery after the VAB, or compared to our study where surgery was only avoided in 25.96 per cent (47 of 181) of the lesions biopsied through VAB.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Gruber et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> conducted a cost-effectiveness and economic impact study in Austria about the use of VAB with 11<span class="elsevierStyleHsp" style=""></span>G needles on a prone biopsy table. Among other things due to the fact that the public health system in most European countries is different from that of the United States, Gruber et al. conducted their economic study not only from the perspective of the hospital (only direct costs), but also from the socioeconomic perspective (direct and indirect costs), and also from both perspectives they were able to prove that the use of VAB instead of harpoon biopsies is more cost-effective and could eventually save over 5 million euros a year in a country the size of Austria with 8.5 million inhabitants.</p><p id="par0260" class="elsevierStylePara elsevierViewall">Gruber et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> only had 29 per cent of patients who avoided surgery after undergoing the VAB, a very similar figure to that of our study (25.96 per cent). This 29 per cent was the percentage of benign lesions that matched the mammographic findings, since unlike Liberman et al.,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18,20</span></a> Gruber considers, like we did in our study, that only benign lesions with good radiopathological correlation avoid surgery after VAB. Consequently, savings in costs will be proportional to the number of benign lesions biopsied with good radiopathological correlation, and if we consider the fact that thanks to breast cancer screening programs the number of biopsies performed will increase and that many of them will prove to be benign, we believe that though the savings we got from each biopsy is modest, it might mean large savings for the public health system if all of them are counted as a whole.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Notwithstanding, our study has some limitations. It is a retrospective study with all the limitations it entails, performed in a single institution instead of being a multicenter study. There is a patient-selection bias, since based on the type of lesion and the preferences of the radiologist one type biopsy or another was conducted, and also the different groups of biopsies are not entirely independent from one another. There are patients who initially underwent a CNB or a VAB and then a VAB or a harpoon biopsy, though each and every single one of these biopsies was counted independently from the others within its group.</p><p id="par0270" class="elsevierStylePara elsevierViewall">This is why the CNB would be presented as the dominant option among the three breast biopsy modalities for breast lesions in general, but due to the low percentage of correct diagnoses that it arrives at in the case of microcalcifications (50 per cent), the VAB would be the modality that is indicated to biopsy microcalcifications due to its high percentage of correct diagnoses (96.77 per cent) and the fact that it is the most cost-effective option compared to harpoon-guided biopsies, which in turn would be the other modality indicated to biopsy microcalcifications.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of human and animal subjects</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors declare that no experiments with human beings or animals have been performed while conducting this investigation.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors confirm that in this article there are no data from patients.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors confirm that in this article there are no data from patients.</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Authors</span><p id="par0290" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0295" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study: PFG, SFMD, LLT and MVIG.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0300" class="elsevierStylePara elsevierViewall">Study idea: PFG and SFMD.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0305" class="elsevierStylePara elsevierViewall">Study design: PFG, SFMD and LLT.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0310" class="elsevierStylePara elsevierViewall">Data mining: PFG, SFMD, ECF and ANB.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0315" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: PFG, SFMD, LLT and MVIG.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0320" class="elsevierStylePara elsevierViewall">Statistical analysis: PFG and MVIG.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0325" class="elsevierStylePara elsevierViewall">Reference: PFG, SFMD, ECF and ANB.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0330" class="elsevierStylePara elsevierViewall">Writing: PFG, SFMD, LLT, MVIG, ANB and ECF.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0335" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks: PFG, MVIG, ANB and ECF.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0340" class="elsevierStylePara elsevierViewall">Approval of final version: PFG, SFMD, LLT, MVIG, ANB and ECF.</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interests</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres804119" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec802366" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres804118" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec802365" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Result variables" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial study" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Cost estimates" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Effect estimate" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Mean ratio estimate" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Financial study. Cost estimate" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Effect estimate" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Mean ratio estimate" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0070" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Authors" ] 10 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-06" "fechaAceptado" => "2016-09-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec802366" "palabras" => array:4 [ 0 => "Cost effectiveness" 1 => "Vacuum-assisted breast biopsy" 2 => "Core-needle breast biopsy" 3 => "Surgical breast biopsy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec802365" "palabras" => array:4 [ 0 => "Costo-efectividad" 1 => "Biopsia mamaria asistida por vacío" 2 => "Biopsia mamaria con aguja gruesa" 3 => "Biopsia mamaria quirúrgica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine the cost effectiveness of breast biopsy by 9<span class="elsevierStyleHsp" style=""></span>G vacuum-assisted guided by vertical stereotaxy or ultrasonography in comparison with breast biopsy by 14<span class="elsevierStyleHsp" style=""></span>G core-needle biopsy and surgical biopsy.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analyzed a total of 997 biopsies (181 vacuum-assisted, 626 core, and 190 surgical biopsies). We calculated the total costs (indirect and direct) of the three types of biopsy. We did not calculate intangible costs. We measured the percentage of correct diagnoses obtained with each technique. To identify the most cost-effective option, we calculated the mean ratios for the three types of biopsies.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Total costs amounted to €225.09 for core biopsy, €638.90 for vacuum-assisted biopsy, and €1780.01 for surgical biopsy. The overall percentage of correct diagnoses was 91.81 per cent for core biopsy, 94.03 per cent for vacuum-assisted biopsy, and 100 per cent for surgical biopsy; however, these differences did not reach statistical significance (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.3485). For microcalcifications, the percentage of correct diagnoses was 50 per cent for core biopsy and 96.77 per cent for vacuum-assisted biopsy (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001). For nodules, there were no significant differences among techniques. The mean cost-effectiveness ratio considering all lesions was 2.45 for core biopsy, 6.79 for vacuum-assisted biopsy, and 17.80 for surgical biopsy.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Core biopsy was the dominant option for the diagnosis of suspicious breast lesions in general. However, in cases with microcalcifications, the low percentage of correct diagnoses achieved by core biopsy (50 per cent) advises against its use in this context, where vacuum-assisted biopsy would be the technique of choice because it is more cost-effective than surgical biopsy, the other technique indicated for biopsying microcalcifications.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Realizar estudio de costo-efectividad de la biopsia por aspiración al vacío (BAV) (9<span class="elsevierStyleHsp" style=""></span>G) guiada por estereotaxia vertical o ecografía comparada con biopsia con aguja gruesa (BAG) (14<span class="elsevierStyleHsp" style=""></span>G) y biopsia con arpón.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Analizamos 997 biopsias mamarias (181 BAV, 626 BAG y 190 arpones). Calculamos costes totales (directos e indirectos) de los tres tipos de biopsia. No calculamos costes intangibles. El efecto a medir fue el “porcentaje de diagnósticos correctos” obtenidos con cada una de las técnicas. Calculamos los ratios medios de los tres tipos de biopsias e identificamos la opción dominante más costo-efectiva.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Costes totales de BAG 225,09<span class="elsevierStyleHsp" style=""></span>€, de BAV 638,90<span class="elsevierStyleHsp" style=""></span>€ y de biopsia con arpón 1780,01<span class="elsevierStyleHsp" style=""></span>€. Porcentaje de diagnósticos correctos globales con BAG 91,81%, BAV 94,03% y biopsia con arpón 100%, sin diferencias significativas (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,3485). En microcalcificaciones, los porcentajes de diagnósticos correctos fueron con BAG 50% y con BAV 96,77%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,0001. En nódulos tampoco hubo diferencias significativas. El ratio medio costo-efectividad considerando todas las lesiones en conjunto, fue para BAG 2,45, BAV 6,79 y arpón 17,80.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La BAG fue la opción dominante para el diagnóstico de lesiones mamarias sospechosas de malignidad en general. En el caso de las microcalcificaciones, el bajo porcentaje de diagnósticos de la BAG (50%) desaconsejan su uso y colocan a la BAV como técnica de elección; la BAV es, además, más costo-efectiva que el arpón, que es la otra técnica indicada para biopsiar microcalcificaciones.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Fernández-García P, Marco-Doménech SF, Lizán-Tudela L, Ibáñez-Gual MV, Navarro-Ballester A, Casanovas-Feliu E. Estudio de costo-efectividad de la biopsia mamaria asistida por vacío <span class="elsevierStyleItalic">versus</span> biopsia con aguja gruesa o arpón. Radiología. 2017;59:40–46.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">P</span> value (proportion comparison test): 0.4944.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CNB: core-needle biopsy; VAB: vacuum-assisted biopsy.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CNB</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VAB</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymmetry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asymmetry<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>microcalcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Distortion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microcalcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nodule \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">374 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nodule in mastectomy scar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nodule<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>microcalcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (8.19 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">423 (91.81 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (5.97 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 (94.03 per cent) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349899.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Matches between anatomopathological findings from the radiological biopsy (CNB and VAB) and findings from the surgical biopsy based on the mammographic finding of all lesions.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CNB: core-needle biopsy; VAB: vacuum-assisted biopsy.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CNB</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VAB</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microcalcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (50 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (50 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.23 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (96.77 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nodule \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (5.56 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">374 (94.44 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8.93 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (91.07 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4866 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349897.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Percentage of matches between anatomopathological findings from the radiological finding (CNB and VAB) and findings from the surgical biopsy in lesions presenting like microcalcifications or nodules.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">P</span> value (Chi-square test of homogeneity) <0.0001.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Harpoon \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CNB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VAB \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microcalcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (31.33 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (13.9 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 (54.8 per cent) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nodule \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">116 (16.3 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">530 (74.4 per cent) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (9.3 per cent) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349896.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Percentage of biopsy modality used based on whether the lesion presents itself as microcalcification or nodule.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">CNB: core-needle biopsy; VAB: vacuum-assisted biopsy; US: ultrasound-guided; STX: stereotaxy-guided.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">STX-CNB<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">STX-VAB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">STX-harpoon<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">US-CNB<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">US-VAB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">US-harpoon \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">€211.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€542.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€240.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€140.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€472.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€170.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349898.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Costs obtained directly from the Fee Regulation Act. 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