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

2. Module Ten- Invasive Procedures

3. 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.

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

5. Needle placement in breast biopsy with ultrasound guidance

6. 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.

7. 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

8. Needle Localization on Mammography

9. Needle localization on Sonography

10. 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.

11. 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.

12. 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

13. FNA technique

14. 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.

15. 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.

16. 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

17. 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

18. Core Biopsy technique

19. 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.

20. Mammotome

22. 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

23. 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.

24. ABBI table

25. 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.

26. 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

27. 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.

28. 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.

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

30. Radiography and MRI imaging

31. FIN