Sonography of the Breast Part III Lecture 12 Invasive Procedures Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS), CCP

Module Ten- Invasive Procedures

Role of Sonography In comparison to Mammography, sonography has a unique advantage of real-time imaging during invasive procedures. This allows direct visualization of the needle tip as it approaches and enters a lesion. Many physicians prefer to use sonography to guide invasive procedures specifically for this reason. The currently accepted method of transducer placement during an invasive procedure includes: Placing the transducer directly over the mass The needle is advanced along the long axis of the transducer parallel to the chest wall. Often the physician will advance the needle and control the transducer in concert. This allows for fine needle movements to be more accurately tracked by the transducer.

The angle of the biopsy needle in relation to the transducer will be parallel. Not 90, 60, or 45 degrees.

Needle placement in breast biopsy with ultrasound guidance

Cyst Aspiration Cyst aspiration is an effective way of Confirming the presence (diagnosis) of a cyst Therapeutically reducing a cyst If a cyst is palpable, a physician can insert a small needle through the skin and withdraw the cyst fluid into a syringe. If the cyst is non-palpable, Sonography or Mammography may be used to locate the cyst and guide the aspiration technique. Biopsy may be required if: Aspirated fluid appears suspicious Cyst is not completely reduced Cyst reoccurs several times.

Needle Localization Breast lesions that present as architectural distortion or micorcalcifications with no visible mass, may require open surgery biopsy for accurate diagnosis. When these lesions are non-palpable, preoperative needle localization is performed to guide the surgeon to the correct location within the breast. Preoperative needle localization requires: Mammography or sonography guidance Placement of a small, hollow needle at the site of the lesion. A flexible wire is placed through the needle and into the breast at the site to be biopsied. The wire often has a hook or barb that holds it in place within the lesion. The wire remains in the breast unit surgery. During Surgery, the surgeon follows the wire directly to the lesion to be excised

Needle Localization on Mammography

Needle localization on Sonography

Fine-Needle Aspiration (FNA) Fine needle aspiration (FNA) uses a very thin (fine) needle, 18 to 25 gauge, attached to a syringe to withdraw a small portion of tissue from a solid tumor. With small, quick, agitating movements, a number of cells may be aspirated into the syringe. Several passes may be needed to gather enough tissue. The tissue is then smeared onto a slide for microscopic examination by a cyotopthologist.

FNA is not considered a true biopsy technique, considering it offers cytologic evaluation of individual cells rather than histologic evaluation of a core sample. Cancer cells tend to break off more easily than benign or normal cells. Therefore, FNA is considered an effective alternative to more invasive biopsy techniques. If the mass is palpable, a physician can perform FNA with no imaging guidance. If the mass is non-palpable, sonography or mammography may be used to locate the lesion and assure accurate retrieval of tissue from the lesion.

Important factors with FNA: Proper instrumentation and technique Proper smear of cells on slide Accurate reading by cytopathologist FNA may not be able to distinguish DCIS from IDC

FNA technique

Advantages of FNA Disadvantages of FNA Does not require open surgical biopsy-less invasive Local anesthesia Safe, cost effective Minimal complications (small hematoma) Results in 1 to 2 hours. Disadvantages of FNA Inadequate tissue sample through small needle Possible false negative Cytologic evaluation is less accurate than histologic evaluation.

Core Biopsy Core biopsy, also known as core needle biopsy (CNB), uses a larger, 14 gauge needle to remove several cores or tissue rather than individual cells. With core biopsy, the arrangement of cells remain intact for accurate histologic evaluation. Several types of biopsy needles are available, including tru-cut manual design (outdated), spring loaded “gun” design, and echogenic needles for sonography guidance.

Cancer cells appear firm and white in a CNB specimen. For lesions that are palpable, physicians can perform core biopsies with no imaging guidance However, Stereotactic Mammography, Sonography, and even MRI are useful as guidance techniques. Cancer cells appear firm and white in a CNB specimen. Advantages of CNB Does not require open surgical biopsy-less invasive Local anesthesia Core sample is sufficient for accurate diagnosis – low false negative Histologic evaluation

Disadvantages of CNB Greater risk of complications than FNB Dense lesions may not be adequately sampled Results in 2 to 3 days. Both mammography and sonography may guide marker placement following core biopsy

Core Biopsy technique

Vacuum-Assisted Biopsy Vacuum-assisted Biopsy (mammotomy) is considered a minimally invasive breast biopsy procedure superior to CNB and less invasive than open surgical biopsy. The procedure is as follows: Use sonography or Stereotactic Mammography Guidance The vacuum-assisted biopsy probe is used as a handheld device The probe uses a large (11 gauge) needle inserted through a ¼ inch skin incision The probe is advanced to the location of the tumor The rotating cutting device and vacuum system retrieves tissue in one single pass Large tissue samples are obtained for biopsy Small lesions may be completely removed.

Mammotome

Advantages of Vacuum-Assisted Biopsy Does not require open surgical biopsy- less invasive Greater accuracy of dense lesions Larger tissue sample Vacuum assisted One needle pass Outpatient procedure Local anesthesia Small tumors may be completely removed Disadvantages of Vacuum-Assisted Biopsy Greater risk of complications Some healthy tissue is removed Possible seroma

Advanced Breast Biopsy Instrument (ABBI) The Advanced Breast Biopsy Instrument (ABBI) is a percutaneous biopsy procedure offering both diagnostic and therapeutic treatment of a breast mass. The ABBI uses a rotating circular knife to remove a cylinder of tissue larger than CNB and Mammotomy. It is also referred to as Large Core Biopsy. ABBI does not require sonography guidance.

ABBI table

The procedure is as follows: Patient lies in a prone position on a specially designed table with an opening in thee chest area. Uses computer-guided, Sterotactic Mammography to pinpoint the lesion. Through a ½ to 1 inch skin incision, the ABBI instrument is advanced into the breast. A 2cm core sample is removed Attempt is made to excise the entire lesion when possible. The specimen is examined for tumor completeness The breast is also re-examined mammographically to complete assure complete removal.

Advantages of ABBI Disadvantages of ABBI Does not require open surgical biopsy – less invasive Pinpoint accuracy Total excision of a tumor Outpatient procedure Local anesthesia Disadvantages of ABBI Greater risk of complications Requires sutures to close incision Healthy breast tissue is compromised

Surgical Biopsy Surgical biopsy has always been the absolute predictor and gold standard in the diagnosis of breast disease. A surgeon performs a surgical biopsy procedure using local, regional, or general anesthesia. An incision is made through the skin of the breast to allow partial or complete tumor removal. An incisional biopsy removes only part of the tumor for histological evaluation. An excisional biopsy removes the entire tumor and some surrounding tissue for histologic evaluation. It is one of the safest surgical procedures performed in day surgery of outpatient surgery facilities.

Specimen Imaging Breast specimen imaging is commonly used to document the successful biopsy and removal of breast lesions. Imaging, following a biopsy or lumpectomy, can be done using mammography or sonography.

A fresh specimen placed on a grid board ready for imaging.

Radiography and MRI imaging

FIN