Breast Cancer (2012) 19:238–241 DOI 10.1007/s12282-012-0340-7
REVIEW ARTICLE
How to choose needles and probes for ultrasonographically guided percutaneous breast biopsy: a systematic approach Takayoshi Uematsu
Received: 13 December 2011 / Accepted: 15 January 2012 / Published online: 10 February 2012 Ó The Japanese Breast Cancer Society 2012
Abstract This article describes a systematic approach to choosing needles and probes for ultrasonographically guided (US-guided) percutaneous breast biopsy under various circumstances. The accuracy of US-guided percutaneous breast biopsy depends upon both the method chosen and lesion characteristics. Target accuracy and proper procedures are essential for predicting the yield regardless of the method chosen. Considering accuracy and cost, vacuumassisted biopsy (VAB) should be offered only to appropriately selected patients. In particular, VAB should be the first choice for US-guided percutaneous breast biopsy of non-mass-like lesions. Keywords Breast Ultrasonographically guided percutaneous breast biopsy Core needle biopsy Vacuumassisted biopsy Non-mass-like lesion
Introduction All lesions found on ultrasonography (US) in symptomatic or asymptomatic women should be sampled by US-guided percutaneous breast biopsy. It is generally considered to be quicker, more readily accessible, and less costly than other localization techniques, and does not require ionizing radiation [1, 2]. Therefore, US is the preferred first-line modality for image-guided breast biopsy.
Early work with percutaneous breast biopsy in the 1950s involved primarily fine-needle aspiration. This was followed by increasing use of core needle biopsy (CNB) in the 1990s because of its superior characterization of benign and malignant lesions and lower frequency of obtaining insufficient samples. Vacuum-assisted biopsy (VAB) devices then became available in the late 1990s and are now commonplace in most breast cancer centers [1, 2]. US-guided VAB has so far proven to be a very accurate method [1, 2]. Some assert that the advantages of US-guided VAB compared to US-guided CNB are concerned mainly with absolute sensitivity. However, US-guided CNB can provide excellent accuracy for most lesions, and the additional benefits provided by US-guided VAB may be slight when considering the high cost and the potential for increased side effects [3]. Therefore, recommending the use of US-guided VAB over US-guided CNB may not be justified. Optimal selection of CNB or VAB for US-guided percutaneous breast biopsy has not been well established. The fact is that choice often depends on personal preference. In this article, we describe how to choose between CNB and VAB for US-guided percutaneous breast biopsy under various circumstances. We also discuss some proposed US-guided percutaneous breast biopsy guidelines that will help the radiologist and surgeon solve the problem of choosing devices for sampling with the help of evidence-based medicine. Tip on US-guided percutaneous breast biopsy
T. Uematsu (&) Breast Imaging and Breast Intervention Section, Shizuoka Cancer Center Hospital, Naga-izumi, Shizuoka 411-8777, Japan e-mail:
[email protected]
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Post-fire needle position verification is the key to predicting the yield of US-guided percutaneous breast biopsy [4, 5]. It is very important to verify whether a post-fire needle position in an orthogonal plane is intra-mass or not before the needle is removed from a patient.
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Our fundamental policy for US-guided percutaneous breast biopsy Our fundamental policy for US-guided percutaneous breast biopsy is to be as minimally invasive as possible and to achieve accurate diagnosis so that appropriate action can be taken. Minimizing underestimation of a lesion by breast biopsy is essential. US-guided VAB has demonstrated promising results with regard to underestimation [1, 2] but has the potential for increased side effects, such as hematoma and scar formation [6, 7]. The reported complication rate of VAB ranges from 0 to 9% with a mean of 2.5% [8]. However, complications with CNB have been reported at a rate of only 0.2% [9]. If it is possible to attain an accurate diagnosis by US-guided CNB, we should select this method for patient comfort. Moreover, modification of ER and PR status between US-guided 18-gauge CNB and resection was observed in a small percentage of cases (6.8% and 7.7%, respectively) [10]. The marker changes between core biopsies and resections were reported to range from 18.1 to 4% [11, 12]. These results demonstrate that our laboratory tests of US-guided 18-gauge CNB are reliable. Therefore, choosing US-guided VAB needs adequate case selection under various circumstances. US-guided CNB In the United States, 14-gauge core needles are the generally accepted minimal needle size for US-guided CNB [13–15]. At Shizuoka Cancer Center Hospital in Japan, an 18-gauge core needle is generally used for US-guided CNB. This is because, in previous studies, data obtained from US-guided 18-gauge core needle breast biopsy for mass lesions was comparable to data obtained from 14-gauge core needle breast biopsy [4]. With regard to mass lesions, target accuracy and proper procedures are essential for predicting the yield regardless of the size of the core needle or the number of core samples [4]. We believe that the thicker the size of the core needle, the greater the potential for side effects to occur. Moreover, a needle thinner than a 14-gauge needle is helpful if the breast tissue is dense and cause difficulties in positioning the needle [1, 4]. The breast tissue of Asian women is denser than that of Western women [16, 17]. Therefore, the selection of an 18-gauge core needle may be reasonable from the viewpoint of handling of the needle.
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good quality than CNB [3]. MammotomeÒ devices are used for US-guided VAB at Shizuoka Cancer Center Hospital. VAB is used most commonly for diagnostic sampling of microcalcifications using stereotaxis [1, 2]. US-guided percutaneous breast biopsy for mass lesions A previous study showed that US-guided CNB provided excellent accuracy comparable to US-guided VAB for mass lesions [18]. The sensitivity (98%) and accuracy rate (98%) for mass lesions using 18-gauge core needles are high [4]. With 14-gauge core needles, the sensitivity (96%) and accuracy rate (96%) for mass lesions are also high [19]. Considering the significantly higher cost of VAB compared to CNB, and the potential for increased side effects, recommending the use of VAB over CNB is not justified [3]. Therefore, CNB should be the first choice for US-guided percutaneous breast biopsy of mass lesions. The concept of ‘‘non-mass-like lesion’’ Selection of an appropriate biopsy device should be based on the morphology of the lesion as seen on breast imaging. Identification of non-mass-like lesions on breast US is very important for accurate interpretation of the US features. Ductal carcinoma in situ (DCIS) and invasive lobular carcinoma usually manifest as non-mass-like lesions on US. It is very important to classify non-mass-like lesions on US in a manner similar to the classification of nonmass-like enhancements on MRI, even though non-masslike findings are not included in the BI-RADS US lexicon [20]. A previous study found that the histological agreement rate between US-guided CNB and surgical histological diagnosis was significantly better for mass lesions than for non-mass-like lesions on US, because non-mass-like US findings were histologically more heterogeneous than mass-like findings and included more instances of DCIS [4]. Therefore, VAB should be the first choice for USguided percutaneous breast biopsy of non-mass-like lesion. US-guided VAB is a better choice for papillomas and complex sclerosing lesions to obtain a larger volume of tissue for diagnosis without surgical excision [1], because intraductal lesions and sclerosing lesions can manifest as non-mass-like lesions on US [21, 22]. US-guided percutaneous breast biopsy for cystic lesions
US-guided VAB Two of the VAB systems currently on the market in Japan are MammotomeÒ (DevicorÒ Medical Products, Cincinnati, OH) and VacoraÒ (CR Bard, Murray Hill, NJ) devices. Both systems allow acquisition of far more tissue of
Ultrasonography is a useful tool for distinguishing simple cysts from complicated cysts and complex cystic and solid masses of the breast. Aspiration recommended for a simple cyst because of symptoms is still appropriately coded BIRADS 2 (benign) and is not included as a positive imaging
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finding for auditing purposes [23]. Asymptomatic complicated cysts with fluid-debris levels or mobile internal echoes are benign (BI-RADS 2) with no follow-up needed [23]. Complex cystic and solid masses are suspicious for malignancy (BI-RADS 4) and merit biopsy [23]. Papillary lesions, including benign and atypical papillomas, and papillary DCIS with or without invasion, are common causes of complex cystic and solid masses [23]. A previous study showed that VAB was more accurate than CNB in diagnosing papillary lesions [24]. Therefore, VAB should be the first choice for US-guided percutaneous breast biopsy of complex cystic and solid masses. US-guided percutaneous breast biopsy for small masses A previous study showed that all the false negative findings using US-guided CNB arose from small masses (\15 mm) [9]. Parker et al. [25] recommended the use of US-guided VAB for masses smaller than 15 mm. Our data using USguided CNB for masses smaller than 15 mm was not inferior to the overall data [4]. In addition, because local anesthesia required for US-guided VAB is quantitatively larger than that for US-guided CNB, small lesions are masked by the local anesthetic and cannot be detected by US. When these lesions are masked, more cores need to be excised to avoid underestimation. However, excising a greater number of cores is harmful to the patient. Therefore, CNB should be the first choice for US-guided percutaneous breast biopsy of small masses.
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discussion are the most important factors to ensure good results from US-guided percutaneous breast biopsy. VAB can be used in cases where the use of CNB has yielded inadequate results. It can be a valuable alternative to surgery in obtaining a definitive diagnosis in cases of imaginghistologic discordance, as the large volume of the tissue samples provides the same diagnostic accuracy as open surgery [26].
Summary Figure 1 shows the decision tree for selecting US-guided percutaneous breast biopsy as the method of choice. The accuracy of CNB is similar to the accuracy of VAB in USguided percutaneous breast biopsy for mass lesions. With regard to mass lesions, accuracy and proper procedures are essential for predicting the yield regardless of the size of the core needle or the number of core samples. Considering the significantly higher cost of VAB compared to CNB and the potential for increased side effects, VAB should be offered only to appropriately selected patients. VAB should be the first choice for US-guided percutaneous breast
US-guided percutaneous breast biopsy for multiple lesions Considering the amount of local anesthetic needed for VAB and its potential for increased side effects, CNB should be the first choice for US-guided percutaneous breast biopsy of multiple lesions. If multiple lesions include a non-mass-like lesion or a complex cystic and solid mass, the lesion should be assessed using US-guided VAB. All other lesions should be assessed using US-guided CNB. We recommend that multiple passes using US-guided VAB in a single breast should be avoided from the standpoint of patient comfort. Multiple passes for multiple lesions in a single breast are better tolerated using CNB. Imaging-histologic discordance and US-guided percutaneous breast biopsy Careful correlation of imaging and histological findings allows the radiologist and the surgeon to identify discordant lesions and recommend prompt re-biopsy or open surgery to avoid delay in diagnosis. In addition, systematic correlation of imaging and histology and multidisciplinary
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Fig. 1 Decision tree for selecting ultrasonographically guided percutaneous breast biopsy as the method of choice
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biopsy of non-mass-like lesions. Close communication between the radiologist, the surgeon, and the pathologist is also essential to obtain good results from US-guided percutaneous breast biopsy.
References 1. O’Flynn EA, Wilson AR, Michell MJ. Image-guided breast biopsy: state-of-the-art. Clin Radiol. 2010;65:259–70. 2. Liberman L. Percutaneous image-guided core breast biopsy: state of the art at the millennium. Am J Roentgenol. 2000;174:1191–9. 3. Heywang-Kobrunner SH, Heinig A, Hellerhoff K, Holzhausen HJ, Nahrig J. Use of ultrasound-guided percutaneous vacuumassisted breast biopsy for selected difficult indications. Breast J. 2009;15:348–56. 4. Uematsu T, Kasami M, Uchida Y, Yuen S, Sanuki J, Kimura K, et al. Ultrasonographically guided 18-gauge automated core needle breast biopsy wit post-fire needle position verification (PNPV). Breast Cancer. 2007;14:219–28. 5. Uematsu T, Kasami M. The use positive core was cytology to estimate potential risk of needle tract seeding of breast cancer: directional vacuum-assisted biopsy versus automated core needle biopsy. Breast Cancer. 2010;17:61–7. 6. Zagouri F, Gounaris A, Liakou P, Chersikos D, Flessas I, Bletsa G, et al. Vacuum-assisted breast biopsy: more cores, more hematomas? In Vivo. 2011;25:703–5. 7. Yazici B, Sever AR, Mills P, Fish D, Jones SE, Jones PA. Scar formation after stereotactic vacuum-assisted core biopsy of benign breast lesions. Clin Radiol. 2006;61:619–24. 8. Park HL, Kim LS. The current role of vacuum assisted breast biopsy system in breast disease. J Breast Cancer. 2011;14:1–7. 9. Parker SH, Burbank F, Jackman RJ, et al. Percutaneous largecore breast biopsy: a multi-institutional study. Radiology. 1994;193:359–64. 10. Kasami M, Uematsu T, Honda M, Yabuzaki T, Sanuki J, Uchida Y, et al. Comparison of estrogen receptor, progesterone receptor and Her-2 status in breast cancer pre- and post-neoadjuvant chemotherapy. Breast. 2008;17:523–7. 11. Tamaki K, Sasano H, Ishida T, Miyashita M, Takeda M, Amari M, et al. Comparison of core needle biopsy (CNB) and surgical specimens for accurate preoperative evaluation of ER, PgR and HER2 status of breast cancer patients. Cancer Sci. 2010;101:2074–9. 12. Uy GB, Laudico AV, Carnate JM Jr, Lim FG, Fernandez AM, Rivera RR, et al. Breast cancer hormone receptor assay results of core needle biopsy and modified radical mastectomy specimens from the same patients. Clin Breast Cancer. 2010;10:154–9.
241 13. Harvey JA, Moran RE, DeAngelis GA. Technique and pitfalls of ultrasound-guided core-needle biopsy of the breast. Semin Ultrasound CT MR. 2000;21:362–74. 14. Liberman L. Clinical management issues in percutaneous core breast biopsy. Radiol Clin North Am. 2000;38:791–807. 15. Parker SH. When is core biopsy really core? Radiology. 1992;185:641–2. 16. Maskarinec G, Nagata C, Shimizu H, Kashiki Y. Comparison of mammographic densities and their determinants in women from Japan and Hawaii. Int J Cancer. 2002;102:29–33. 17. Maskarinec G, Pagano I, Chen Z, Nagata C, Gram IT. Ethnic and geographic differences in mammographic density and their association with breast cancer incidence. Breast Cancer Res Treat. 2007;104:47–56. 18. Philpotts LE, Hooley RJ, Lee CH. Comparison of automated versus vacuum-assisted biopsy methods for sonographically guided core biopsy of the breast. Am J Roentgenol. 2003;180: 347–51. 19. Youk JH, Kim EK, Kim MJ, Oh KK. Sonographically guided 14-gauge core needle biopsy of breast masses: a review of 2,420 cases with long-term follow-up. Am J Roentgenol. 2008;190: 202–7. 20. American College of Radiology. Breast imaging reporting and data system (BI-RADS). 4th ed. Reston: American College of Radiology; 2003. 21. Hsu HH, Yu JC, Hsu GC, Chang WC, Yu CP, Tung HJ, et al. Ultrasonographic alterations associated with the dilatation of mammary ducts: feature analysis and BI-RADS assessment. Eur Radiol. 2010;20:293–302. 22. Takei J, Tsunoda-Shimizu H, Kikuchi M, Kawasaki T, Yagata H, Tsugawa K, et al. Clinical implications of architectural distortion visualized by breast ultrasonography. Breast Cancer. 2009;16: 132–5. 23. Berg WA, Sechtin AG, Marques H, Zhang Z. Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 2010;48:931–87. 24. Shin HJ, Kim HH, Kim SM, Yang HR, Sohn JH, Kwon GY, et al. Papillary lesions of the breast diagnosed at percutaneous sonographically guided biopsy: comparison of sonographic features and biopsy methods. Am J Roentgenol. 2008;190:630–6. 25. Parker SH, Klaus AJ, McWey PJ, Schilling KJ, Cupples TE, Duchesne N, et al. Sonographically guided directional vacuumassisted breast biopsy using a handheld device. Am J Roentgenol. 2001;177:405–8. 26. Kim MJ, Kim EK, Lee JY, Youk JH, Park BW, Kim SI, et al. Breast lesions with imaging-histologic discordance during USguided 14G automated core biopsy: can the directional vacuumassisted removal replace the surgical excision? Initial findings. Eur Radiol. 2007;17:2376–83.
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