Vacuum-Assisted Breast Biopsy and Excision for Breast Lesions: A Systematic Review and Meta-analysis of Malignant Upgrade in B3 Lesions

Vacuum-assisted breast biopsy (VAB/VABB) and vacuum-assisted excision (VAE) serve distinct diagnostic and therapeutic roles, requiring pathway-specific evaluation of their outcomes. This systematic review reconstructed a report-level and outcome-level dataset from 26 publications, of which 18 were reviewed in full text and 8 remained incompletely retrieved. Reports without complete full text were retained for narrative context but excluded from quantitative synthesis. Five full-text studies contributed 98 malignant upgrades among 844 B3 lesions after diagnostic VAB/VABB. The pooled proportion was 11.23% (95% confidence interval [CI], 7.22%-17.04%; 95% prediction interval [PI], 4.56%-25.06%; I² = 60.8%). Three full-text studies of second-line VAE reported study-specific upgrade proportions from 5.1% to 21.4%; these estimates were not pooled because selection pathways and case mix differed substantially. Post-VAE radiologic removal, absence of residual lesion, and recurrence-free outcomes ranged from 86.0% to 99.2% across five full-text cohorts but were not combined because they represented different endpoints and follow-up intervals. Only one fully retrieved study provided reconstructable diagnostic 2 × 2 data, precluding a diagnostic meta-analysis or hierarchical model. Certainty was very low for the principal observational outcomes and low for the single randomized comparison. The evidence supports pathway-specific interpretation and multidisciplinary decision-making, not universal superiority over core needle biopsy or equivalence to surgical excision.