INTRODUCTION

Breast screening by mammography has increased

awareness of breast cancer, which is the second most

common cause of death in females.

Screening

mammography has led to increased discovery of

localized breast cancer and has resulted in increase in

number of biopsies with majority being performed under

imaging guidance.

The resultant diagnosis finally leads

to early and appropriate patient care and subsequent

neoadjuvant and surgical treatment in case of

malignancy.

The image guided percutaneous breast

biopsy procedures are minimally invasive, cause less

breast scarring, save time and money, and relieve the

patient of the anxiety of going to the operation theatre.

Majority, i.e. 70 - 80% of image detected suspicious

breast lesions biopsied under image guidance turn out to

be benign thus obviating a need for a surgical

procedure.

In addition, patients who are diagnosed as

having cancer undergo fewer operations as the disease

is detected at a non-clinical earlier stage.

6,7

Masroor

et al. studied the cost effectiveness of percutaneous

breast biopsy to open surgical biopsies, and reported

that the cost saving per patient was 253 US dollars.

Similarly, other studies reported that core needle biopsy,

in comparison to open surgical biopsy, lead to cost

saving from 51 to 96%.

9,10

Image guided vacuum-

assisted core biopsy yields a high diagnostic accuracy

predominantly of lesions with low to intermediate risk of

malignancy. Approximately half of the cases obviate the

need for surgical removal with resultant better cosmetic

result.

The National Comprehensive Cancer Network (NCCN),

in the most recent Clinical Practice Guidelines, has

recommended percutaneous breast biopsy for lesions

categorised as Breast Imaging Reporting and Data

System (BI-RADS) 4 (suspicious abnormality); or

BI-RADS 5 ( highly suggestive of malignancy).

Indeed, breast program accrediting bodies recommend

image guided biopsy as the standard of care, and

recommend this as one of the measures of quality when

accrediting breast imaging centres.

A number of institutions in Pakistan are at present in the

phase of setting up sections of breast imaging and

intervention; and are faced with the challenges of learning

how to perform image guided breast interventions. The

options available for such interventions and the

appropriate modality for image guidance are not widely

known among many clinicians.

The objective of this review was to describe and discuss

the different aspects of image guided biopsy techniques

along with the authors’ practices, their indications and

contraindication along with their merits and demerits.

METHODOLOGY

Studies published in English language from 2000 to

2015 were searched by using key words “ultrasound

guided biopsy, stereo-tactic biopsy, needle localization,

MRI guided biopsy and sampling techniques” on

PubMed, Medline and Google Scholar. Relevant

publications describing the localizing and sampling

techniques of breast lesions under various imaging

modalities along with their technical aspects, cost

efficacy and merits and demerits, were included. Overall

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (6): 521-526 521

REVIEW ARTICLE

Imaging Guided Breast Interventions

Imrana Masroor, Shaista Afzal and Saira Naz Sufian

ABSTRACT

Breast imaging is a developing field, with new and upcoming innovations, decreasing the morbidity and mortality related

to breast pathologies with main emphasis on breast cancer. Breast imaging has an essential role in the detection and

management of breast disease. It includes a multimodality approach, i.e. mammography, ultrasound, magnetic resonance

imaging, nuclear medicine techniques and interventional procedures, done for the diagnosis and definitive management

of breast abnormalities. The range of methods to perform biopsy of a suspicious breast lesion found on imaging has also

increased markedly from the 1990s with hi-technological progress in surgical as well as percutaneous breast biopsy

methods. The image guided percutaneous breast biopsy procedures cause minimal breast scarring, save time, and relieve

the patient of the anxiety of going to the operation theatre. The aim of this review was to describe and discuss the different

image guided breast biopsy techniques presently employed along with the indications, contraindication, merits and

demerits of each method.

Key Words: Breast cancer. Percutaneous biopsy. Breast imaging.

Department of Radiology, The Aga Khan University Hospital,

Karachi.

Correspondence: Dr. Shaista Afzal, Associate Professor,

Department of Radiology, The Aga Khan University Hospital,

Karachi.

E-mail: shaista.afzal@aku.edu

Received: March 27, 2015; Accepted: February 02, 2016.

Imrana Masroor, Shaista Afzal and Saira Naz Sufian

522 Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (6): 521-526

56 studies were selected after analysing and evaluating

the papers. Historical details were collected from the

older reviews. Results were described as localizing and

sampling techniques.

Localizing techniques: The localization of suspicious

breast lesions is performed under ultrasound, stereo-

tactic and MRI guidance with ultrasound being the most

commonly employed.

Ultrasound: Presently, ultrasound is being increasingly

used for breast interventions which may be diagnostic

like percutaneous biopsy of breast lesions/axillary

lymphadenopathy and preoperative wire localization or

therapeutic like cyst aspirations and abscess drainage.

The ultrasound guided core needle biopsy is now the

preferred method for performing most breast biopsies

with sensitivity of 97.5%.

The advantages of ultrasound-guided biopsy are: short

duration of the procedure, less discomfort, better

tolerated by the patient, reduced cost, low risk of

infection, high yield of accurate samples as the

procedure is performed in real time, and lastly since this

requires no radiation exposure or intravenous (IV)

contrast, it is the localizing technique of choice in

pregnant patients.

14,15

This localizing technique is cost

effective in comparison to biopsies under stereotactic

guidance.

16,17

The equipment required for ultrasound-guided breast

interventions are high frequency transducer and biopsy

device.

Micro-calcifications detected on ultrasound in addition to

mammography are more often malignant

and can also

be sampled using ultrasound, especially under circums-

tances when stereotactic biopsy is not feasible, e.g. due

to limitations of patient positioning or breast size. The

contraindications to ultrasound-guided breast biopsy

include non-visualization of lesion sonographically, un-

cooperative patient etc.

For the procedure, the patient is comfortably positioned.

Under ultrasound guidance and after usual preparation,

the needle is advanced and inserted into the lesion and

the required number of samples are obtained, (Figure 1)

documenting the needle placement in 2 orthogonal

planes.

Stereotactic guidance: The number of women

diagnosed with ductal carcinoma in situ (DCIS) has

increased in the past few years as a result of screening

mammography. The commonest mammographic feature

of DCIS is micro-calcification, which is conveniently

sampled with stereotactic biopsy.

The accuracy of

stereotactic biopsy instrument is influenced by the

sampling technique, i.e. core needle biopsy (CNB)

versus vacuum assisted biopsy (VAB) with increasing

accuracy ranging from 87% to 97% when larger samples

are obtained. False negative rate being 1.2 - 5.4%.

The stereotactic devices were added on to the standard

mammography units at its inception with the patient in

upright sitting position (Figure 2). Prone biopsy units

were introduced in mid-1980's with the patient lying

prone for the procedure. This reduced patient

movement, improved patient comfort, and eliminated

syncope in addition to enabling the biopsy of lesions

close to the chest wall due to the gravitational

influence.

When micro-calcifications are sampled, the specimen

radiography is performed to confirm the presence of

representative calcifications. A minimum 3 flecks of

calcification should be present in at least 2 cores and, if

possible, 5 or more flecks in 3 cores.

For the procedure, initially scout images are achieved to

confirm the presence of suspicious calcifications or

lesion in the biopsy region, following which stereo-

images are obtained (Figure 2). The coordinates of the

final 3 dimensions are derived by triangulation formulas

making sure the presence of adequate stroke margin to

avoid damage to the biopsy apparatus.

Figure 1: Ultrasound guidance for core needle biopsy. (A) Measurement of

lesion. (B) Echogenic needle seen within the lesion.

Figure 2: (A) Mammography unit with add-on stereotactic device. (B) Stereo

images.

The breast is cleansed and draped to achieve asepsis;

and under local anaesthesia, biopsy is performed after

confirming accurate needle placement followed by

specimen radiography, if suspicious calcifications were

targeted. Radio opaque markers/clips are placed to

mark the position of the biopsy site.

The complication rates of stereotactic biopsy are low

and include minimal pain, bruising, formation of

hematoma and abscess with 0.1% requiring surgical

drainage

and seeding of tumour cells which does not

appears to be of clinical implication.

Communication

with the patients and educating them regarding these

complications before the procedure, helps diminish

patients’ apprehension and anticipated pain.

One of the limitations of the stereotactic biopsy is non-

applicability in a thin or small breast, as adequate breast

thickness is not available while in compression. For

patients weighing more than 300 pounds, prone table

cannot be used due to weight restrictions from most

vendors. Another important limitation is related to the

gauge of the biopsy device, i.e. CNB/VAC which may

result in the upgrading of DCIS on definitive surgery.

Magnetic resonance imaging (MRI): Due to the proven

sensitivity and specificity of contrast enhanced MRI for

the detection of breast lesions, especially those not

detected on other imaging modalities,

there is a

resultant increase in demand for its utility in obtaining

samples for histological evaluation.

Once a lesion is

categorized as BI-RADS 4 or 5 and only seen on MRI,

then this warrants re-examination of mammograms and

targeted ultrasound, i.e. second look to evaluate for a

correlate. If initially obscured findings are visible on re-

look mammography or ultrasound, then the MRI

detected lesions should be biopsied under ultrasound or

mammographic guidance. Up to 57% of lesions detected

only on MRI can be sonographically correlated and

hence biopsied.

MRI guided biopsy is recommended

only if no correlate detected on second-look ultrasound.

The MRI guided biopsy is technically more complex,

costly, and time consuming due to reasons like the

availability of MRI compatible biopsy device and patient

to be moved in and out of the magnet bore during the

procedure. After obtaining localization images,

intravenous contrast is administered to locate suspicious

lesion. Computerized calculations aid in determining the

precise location of the lesion in relation to the grid.

A co-axial technique is used for most MRI guided

biopsies using MRI compatible needles (i.e. titanium).

The limitation is the difficulty in localization of small

lesions and that of time since the breast parenchyma

shows gradual increase in enhancement, which may

obscure the suspicious lesion with rapid contrast

washout. The general limitations of MRI like

claustrophobia and patient body habitus also apply for

this procedure.

Sampling Techniques:

Fine needle aspiration (FNA): The technique is

essentially unchanged since its inception in the 1930's.

This procedure diagnoses the breast lesions with high

accuracy (72 - 94%), although it depends on operator's

skill and experience.

31-33

It has a miss-rate of 5%,

requiring a repeat biopsy or further investigation.

FNA being minimally invasive and cost effective

was

the most widely used technique for breast biopsy before

the 1990s, but it had many limitations like operator

dependency, non-availability of skilled cytopathologist

for rapid interpretation of results at many centres. Thus

making rapid evaluation impossible.

The pathologist

can only report benign or malignant cells in the aspirate

and cannot comment on in situ or invasive carcinoma or

on hormone receptor status.

The advantages of CNB

has led to overall decrease in its utilization.

FNA is still

invaluable for the evaluation of axillary lymph nodes or

lesions adjacent to breast implants or lesions near

pectoral muscles which are very close to chest wall.

Imaging guided breast interventions

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (6): 521-526

523

Figure 3: Needle localization of micro-calcifications and specimen

radiography showing clustered micro-calcifications.

Figure 4 (A,B,C): (A) Left breast lump, that was subjected to ultrasound

guided core biopsy and clip placement.

(B) Post neoadjuvant chemotherapy

mammography shows significant reduction in size of the lesion. (C) Needle

localization of metallic clip under stereotactic guidance.

The technique involves utilization of aseptic technique

and under ultrasound guidance 19 to 25-G needles are

used. For maximum safety of the underlying structures,

the needle is inserted at a shallow angle achieved by

selecting the entry site of needle at a distance of 1 - 2 cm

from the transducer.

In most instances, 2 passes into

the lesion at different angles and with moderate suction

are sufficient. The radiologist prepares the smears from

the aspirate by fixing in alcohol for Papanicolaou and

Diff-Quik stain and preliminary diagnosis is provided by

the on-site cytopathologist.

Core needle biopsy (CNB): A growing use of CNB

technique was witnessed in the 1990's on account of

adequacy of sample and hence accurate differentiation

of benign from malignant lesion.

After the identification of the lesion, the overlying skin is

marked, cleansed and local anaesthesia is injected.

A skin incision is given to allow insertion of core needle

device in a spring loaded automated gun. Usually a

14-gauge needle is used.

The biopsy gun retrieves

small cores of tissue, thus allowing more adequate

histological evaluation. Micro-calcifications require more

cores than solid lesions.

37-39

The needle is directed into

the lesion parallel to chest wall in order to avoid damage

to chest wall structures. After adequate samples have

been taken, pressure is applied at biopsy site. Post-

procedure specimen radiography is done, especially if

the biopsy was done for suspicious micro-calcifications

seen on mammogram. It is recommended to obtain a

minimum of 4 non-fragmented specimens to enhance

the yield of the procedure under ultrasound guidance.

A major limitation of CNB is under estimation of disease,

such as with atypical ductal hyperplasia (ADH) and

ductal carcinoma in situ (DCIS).

The miss-rate for core needle biopsy has been reported

as 8 - 12% and the under estimation rates of 3.4% to

100% have been reported.

Vacuum-assisted breast biopsy (VABB): The

limitations of core biopsies lead to development of VABB

in the late 1995.

The initial technique has potentially

reduced the under-estimation and false negative rates. It

is same as CNB and under imaging guidance single

insertion of an 8 or 11 gauge needle facilitates faster

retrieval of large tissue volumes in contiguous

specimens of tissue. VABB with an 11-G needle can be

employed for complete resection of lesions that are

1.0 cm or less in diameter and an 8-gauge needle is

capable of resecting breast lesions less than 3.0 cm in

diameter.

It is associated with complications like pain

and haemorrhage but offers acceptable cosmetic

outcome.

The histopathological diagnosis after VABB

is known to be reliable and almost equivalent to open

surgical biopsy, as quoted in some studies.

Surgical excision following needle localization: The

procedure is performed under image guidance, i.e.

mammography, ultrasound, and MRI. After the usual

preparation, a hook-wire is placed inside a rigid

introducer needle and advanced into the suspicious

lesion; and once its location within the lesion is

confirmed, the needle is taken out and the hook wire is

left in place. The hook wire is self-retaining and anchors

to the tissue which prevents further advancement,

withdrawal, and movement (Figure 3).

Mammographic images are provided to the surgeon and

the radiologist describes the lesion location in relation to

the wire. Specimen imaging should be obtained to verify

the removal of suspicious lesions/calcifications (Figure 3).

A working alliance among an experienced surgeon,

radiologist and pathologist is crucial to achieve desired

surgical results. Needle localization followed by open

surgical biopsy provides an opportunity for rapid and

precise excision resulting in minimal tissue damage

with low miss-rates (-1.1%) and false negative rates

(1.0%).

The open surgical biopsy for initial diagnosis is

an invasive test, hence it is not recommended by NCCN

as an initial procedure.

Radio-opaque metallic marker/clip placement:

Radio-opaque metallic markers/clips are placed after

image guided biopsy in almost all cases, and

mammograms obtained to confirm its position. A single

clip should ideally be placed in the center of the lesion.

It localizes the tumor bed with radio-opaque markers

prior to the institution of chemotherapy and facilitates

breast conservation surgery with excision of entire tumor

bed even after complete clinical and radiological

response (Figure 4).

51,52

The marker is also placed

after biopsy of non-palpable or too small breast lesion

with possibility of complete disappearance after

biopsy.

Post-deployment clip migration is a common

complication associated with this procedure and may be

seen immediately after the biopsy or on follow-up

mammography.

There are 3 categories of clip markers,

i.e. commercial metallic markers, which include stainless

steel and plain titanium clips, metallic markers covered

with bio-absorbable substance, and markers that can be

locally assembled by using the Montreal technique.

55,56

CONCLUSION

Percutaneous imaging guided biopsy can provide a

diagnosis with minimum patient trauma as it is minimally

invasive and also saves time. It provides an opportunity

to the breast surgeon to discuss with the patient the

surgical options, based on the histopathology results. A

multi-modality approach, i.e. mammography, ultrasound,

and magnetic resonance imaging can be utilized for

optimum patient care and accurate diagnosis.

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