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It also has been our observation that the underdiagnosis of clinically and radiologically occult invasive carcinomas cannot be avoided, even with seemingly good radiologic-pathologic correlation. As Verkooijen et al. have observed, unsampled occult carcinoma at or near targeted, pathologically definable lesions such as benign calcifications may be underdiagnosed, albeit rarely, by image-guided biopsy and may be regarded as a false-negative result. Furthermore, clinically and radiologically occult invasive carcinoma may not be detected when located at a distance from the imaging target. In our study, we did not address the issue of such “incidental” carcinomas because it was beyond the scope of our article.1 We simply wanted to draw attention to the incidence of false-negative diagnoses of clinically suspicious, often radiologically visualized lesions, possibly leading to an “avoidable” delay in the diagnosis of carcinoma when core needle biopsy is performed without image guidance. Radiologic-pathologic correlations mandated for image-guided biopsies performed by the radiologist are specifically designed to recognize false-negative results on a lesion visualized by imaging. As Verkooijen et al. aptly point out, unexplained false-negative diagnoses do occur with image-guided biopsies, even after adequate radiologic-pathologic concordance. As they suggest, using an 11-gauge, vacuum-assisted core needle biopsy further reduces the likelihood of unexplained false-negative results because of the increase in sampling with larger tissue cores. Occult tumors occurring in the same breast, when spatially unrelated to the target lesion, are not likely to be diagnosed even with vacuum-assisted, 11-gauge core needle biopsy and therefore also are “unavoidable.” We agree that it is important to alert physicians and patients that a tumor may go undetected, even with image-guided core needle biopsy, although this is a rare occurrence. We would reemphasize the need to correlate clinical, radiologic, and pathologic findings for nonimage-guided core needle biopsies before accepting nonspecific benign pathologic findings as a definitive diagnosis.

We appreciate the opportunity to clarify this issue.