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- MRI-guided breast interventions
Photograph obtained during stereotactic biopsy with patient prone on dedicated table shows gauge directional vacuum-assisted biopsy probe in breast.
Imaging-Guided Interventional Breast Techniques eBook by - | Rakuten Kobo
View larger version 50K Fig. Specimen radiographs show calcifications arrows in multiple samples. All calcifications were removed. Craniocaudal mammogram after biopsy shows localizing clip placed at biopsy site. Clip can serve as marker for subsequent localization, if necessary. Histologic analysis showed benign fibroadenoma with calcification. Diagnosis was concordant with mammographic features, and no surgery was performed.
Because most lesions containing ADH or DCIS contain calcifications, histologic underestimates at percutaneous biopsy are most often encountered in calcific lesions [ 57 , 58 ]. Both ADH and DCIS underestimates decrease the frequency with which percutaneous biopsy spares a surgical procedure: an ADH underestimation leads to a recommendation for surgical biopsy, and a DCIS underestimation may require that the patient have a second operation to assess the axilla.
Directional vacuum-assisted biopsy diminishes but does not eliminate the problem of histologic underestimates. Surgical, Norwalk, CT [ 68 , 69 ]. It is prudent to suggest that a diagnosis of ADH with any existing percutaneous biopsy technology is an indication for surgical excision because of the high prevalence of carcinoma in these lesions.
Lesions yielding DCIS at percutaneous biopsy may contain areas of invasive carcinoma at surgery, regardless of whether the biopsy was performed with a gauge automated needle, a directional vacuum-assisted biopsy probe, or a larger biopsy device. In clinical follow-up studies after stereotactic gauge automated core biopsy, the frequency of missed carcinoma averaged 2. Although this frequency is comparable to the frequency of missed cancer at needle localization and surgical biopsy, which has an average cancer miss rate of 2.
The radiologist can take several steps to diminish the likelihood and potential impact of a false-negative diagnosis. Optimizing technique, particularly with respect to lesion targeting, can maximize the chance that the needle will sample the lesion [ 58 ]. For lesions evident as calcifications, calcifications should be identified on specimen radiographs; if calcifications are not observed on specimen radiographs and the diagnosis is benign, additional tissue sampling may be warranted even if calcifications are identified histologically. Careful correlation of the imaging and histologic findings will allow the radiologist to identify discordant lesions prospectively and recommend prompt rebiopsy, avoiding delay in diagnosis.
And finally, the radiologist should emphasize to the patient the importance of follow-up mammography after benign percutaneous biopsy, so that any interval change can be identified and evaluated. Percutaneous core biopsy is most often used to evaluate nonpalpable lesions that are suspicious for malignancy i.
If percutaneous core biopsy of a category 4 lesion yields a benign diagnosis concordant with the imaging characteristics as it usually does , the woman is usually spared the need for diagnostic surgical biopsy. The usefulness of percutaneous core biopsy for category 5 lesions depends on the surgical treatment protocol that would otherwise have been used [ 74 ]. If the protocol in the absence of percutaneous biopsy would be to perform a diagnostic surgical biopsy followed by a second therapeutic surgery if carcinoma was found, performing a percutaneous biopsy could spare a surgical procedure.
If the protocol in the absence of percutaneous biopsy would be to confirm the diagnosis of carcinoma with a frozen section and then to perform a one-stage therapeutic operation, percutaneous biopsy would not spare the patient a surgical procedure. The traditional management of BI-RADS category 3 lesions is short-term follow-up mammography, which is less invasive and less expensive by a factor of 8 than percutaneous core biopsy [ 83 ].
Biopsy could be considered in a small subset of category 3 lesions—for example, if follow-up is unavailable or compromised because of geographic considerations, an impending pregnancy, or impending breast augmentation or reduction surgery , if a synchronous carcinoma is present especially in the ipsilateral breast and breast-conserving surgery is planned , if the patient is at high risk for developing breast cancer, or if the patient's anxiety precludes short-term follow-up.
The goal of percutaneous biopsy is diagnosis, not treatment. However, percutaneous biopsy may result in complete removal of the mammographic lesion, particularly if a large volume of tissue is obtained [ 84 , 85 ]. Complete removal of the mammographic target does not ensure complete excision of the abnormality. Therefore, it is desirable to place a localizing clip at the biopsy site when the mammographic lesion is removed Fig. Are there scenarios in which complete removal of the mammographic target is desirable?
Although complete lesion removal is generally not the goal of percutaneous biopsy, theoretically reasons exist why it may be advantageous in some cases. Complete lesion removal may reduce or eliminate sampling error, perhaps decreasing the likelihood of histologic underestimation, imaging—histologic discordance, and rebiopsy [ 85 ].
The benefits of complete excision versus sampling should be assessed in future work, particularly with the development of new instruments for percutaneous biopsy that allow larger volume tissue acquisition. The ABBI system is a tissue acquisition device coupled with a stereotactic table. It is available with a variety of cannula sizes ranging up to 2 cm.
The ABBI device can obtain a specimen extending from the subcutaneous tissue to beyond the lesion, potentially removing the entirety of a small mammographic target in a single specimen [ 87 ]. In spite of initial enthusiasm regarding this device, the ABBI system has many disadvantages. The large volume of tissue obtained reportedly up to 13 cm 3 is likely to cause more scarring and deformity with little benefit to women with benign disease, who account for most women who come to biopsy. The 1.
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It has not yet been established that the ABBI has benefits that outweigh its disadvantages. Displacement of benign or malignant epithelium into tissue away from the target lesion may occur during a variety of breast needling procedures, including fine-needle aspiration, core biopsy, directional vacuum-assisted biopsy, local anesthetic injection, and suture placement [ 67 ].
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Epithelial displacement can cause interpretive problems for the pathologist: displaced DCIS can mimic infiltrating ductal carcinoma. Specific histologic findings suggesting epithelial displacement include fragments of epithelium in artifactual spaces in the breast parenchyma, morphologic evidence of a needle track hemorrhage, fat necrosis, inflammation, hemosiderin-laden macrophages, or granulation tissue , and absence of surrounding tissue reaction such as one excepts to see with infiltrating carcinomas.
Epithelial displacement may be less frequent after vacuum-assisted biopsy than after automated core biopsy [ 67 ]. The largest study to address the issue of epithelial displacement at large-core needle breast biopsy was conducted by Diaz et al. In surgical excision specimens in women with a prior diagnosis of cancer by large-core needle biopsy, Diaz et al. The inverse relation between the amount of tumor displacement observed and time to excision suggests that tumor cells do not survive displacement. Few data address the long-term impact of epithelial displacement.
In a study of stagematched palpable invasive breast cancer treated by mastectomy, Berg and Robbins [ 89 ] noted no difference in year survival between women whose cancer is diagnosed on aspiration biopsy and those whose cancer is diagnosed with open surgical biopsy. In a study of 74 women with nonpalpable breast cancer diagnosed by needle localization and surgical biopsy, Kopans et al.
Mastectomy was performed in all the patients in the study of Berg and Robbins and most of the patients in the study of Kopans et al. Additional study is needed to assess the clinical significance of epithelial displacement in the breast, including long-term follow-up of women with cancer diagnosed by percutaneous biopsy and treated with breast-conserving surgery. Other accepted reasons for a second biopsy include possible phyllodes tumor the most common reason for rebiopsy after sonographically guided gauge automated core biopsy in one series [ 17 ] , pathologist's recommendation, discordance between imaging and histologic findings, and inadequate tissue a rare event at percutaneous core biopsy [ 17 , 62 , 91 , 92 ].
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Controversy exists regarding the need for surgical excision after percutaneous core biopsy diagnosis of other specific entities [ 93 ] including papillary lesions [ 94 ], radial scar [ 70 ], atypical lobular hyperplasia [ 95 , 96 , 97 ], and lobular carcinoma in situ [ 95 , 96 , 97 ]. Because of the low frequency of each of these diagnoses, these issues may best be addressed by the cooperative efforts of multiple institutions. Philpotts et al. The extent of the radiologist's responsibilities for follow-up after percutaneous biopsy has not yet been determined, but these responsibilities exist.
These missed cases of cancer were detected by means of mammographic progression at 6 and 18 months after biopsy. Lee et al. These studies illustrate the importance of follow-up after percutaneous breast biopsy. The follow-up interval after a benign percutaneous biopsy diagnosis is not standardized.
Suggested intervals to the first follow-up mammogram have ranged from 6 months [ 70 ] to 1 year [ 39 ], with some investigators suggesting a varied interval depending on the histologic findings 1 year for a specific benign diagnosis and 6 months for a nonspecific benign diagnosis [ 71 ]. Patients often fail to comply with follow-up recommendations [ 98 ].
Protocols for tracking follow-up data often vary, but all require substantial allocation of time and resources. In spite of these difficulties, follow-up is essential [ 99 ]. As eloquently stated by Berlin [ ]:.
Whatever the extent of these responsibilities, they are greater today than they were yesterday, and they are likely to be greater tomorrow than they are today. The progress in percutaneous biopsy in the last decade has created a revolution in breast diagnosis analogous to the revolution in treatment accomplished by the introduction of breast-conserving surgery. Techniques have been developed for obtaining tissue specimens from breast lesions, and these techniques have been evaluated and compared. Studies correlating percutaneous biopsy and surgical histologic findings have taught us which percutaneous diagnoses are less reliable and warrant surgical excision.
Analyses of cost-effectiveness have shown that not only is percutaneous biopsy less invasive, less deforming, and faster than surgery, but it also decreases cost. Although advances have been made, much work remains to be done.
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Newer technologies should be assessed with respect to their accuracy, safety, and cost-effectiveness. Protocols must be developed to optimize the choice of biopsy method for different lesions. Long-term follow-up is needed to determine the impact of the newer biopsy technologies on the mammographic pattern, to better delineate the false-negative rate of percutaneous breast biopsy, and to clarify the biologic implications of epithelial displacement in the breast. Further investigation is necessary to define the appropriate clinical context for breast MR imaging and to develop technology for MR imaging—guided breast biopsy.
And finally, the future may allow an expansion of the role of percutaneous techniques into the realm of therapy. Perhaps the day will come in the new millennium when we can offer a woman not only minimally invasive diagnosis but also minimally invasive treatment of her breast cancer. This is the fifth in a series of Centennial Dissertations that the AJR is publishing this year in honor of the former presidents of the American Roentgen Ray Society, two of whom are pictured above. I offer thanks to Steve Parker, for starting it all; to D.
David Dershaw, for creating a work environment that allows us to ask questions and seek answers; to Michelle P. Sama, for photographic assistance; and to David C. Perlman, for invaluable support in this and all things. American Journal of Roentgenology. Site Tools.
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MRI-guided breast interventions
By author Laura Liberman. May , Volume , Number 5. Centennial Dissertation.