Ultrasound Guided Interventional Procedures of the Breast - SD

Ultrasound Guided Interventional Procedures of the Breast

My name is Dr. Catherine Piccoli, and I'll be speaking about ultrasound guided interventional procedures of the breast.

Objectives

The objectives of the talk are to discuss the technical aspects of cyst aspiration and fine needle aspiration biopsy of solid masses and core biopsy.

We'll also discuss what we do with the results that we obtain from our core biopsies and cytology results, as well as discuss which cystic lesions should be aspirated or biopsied.

Needle Localization Techniques

The gold standard in breast biopsy is surgical biopsy in the operating room. Very often radiologists are involved in localizing the lesions using needle placement, and we use mammography, ultrasound and MRI for that purpose.

Mammographic Needle Localization

In mammography, we can place the breast in a compression device with an alphanumeric grid placing the mass within the fenestrated window, and we can place a needle into the breast mass.

And we do that by lighting a little light right above the needle and advancing the needle straight into the lesion.

And then we'll take some mammographic images showing the relationship of the needle to the mass.

And once the surgery has taken place, we'll also perform some specimen radiographs to show that the lesion that we localized was indeed removed.

Ultrasound Guided Needle Localization

We can also perform needle localization using ultrasound guidance, and we use a similar technique as we do in biopsy, but generally we'll leave both the hook wire and commonly the needle in place and send the patient from the radiology suite off to the operating room.

When I do needle localizations under ultrasound, I like to place the needle in a transverse orientation relative to the breast.

And this is because when the patient sits up, the needle travels with the breast instead of against the breast, and so it's more likely to stay in place rather than being pulled away by the breast as it drops.

When she stands up, we like to place the needle through or immediately posterior to the lesion.

With the needle tip lying approximately one half to one centimeter beyond the lesion.

Some surgeons like the needle left in place. They use the needle as a stiff guide to determine where the mass is relative to the entrance of the needle site.

Once they know where they wanna make their cut, they will remove the needle and follow the wire to the lesion.

Ideally, when the wire is left in place, the thick portion of the wire, which is close to but not directly at the hook of the wire, should be at the level of the lesion.

In some cases, we might instill some blue dye. It's very small amount is required.

About 0.1 cc is all that's necessary.

And this will also help the surgeon find the lesion.

And this is an example of a mass, which was localized using ultrasound, and we can see that the needle is directly through but at its more inferior or posterior aspect of the lesion.

And when we're done with the procedure itself, we like to take images and label them so that the surgeon understands where the needle is relative to the mass.

Performing a mammogram is also not a bad idea. That also gives a little more spatial orientation for the surgeon.

And then just like mammographically guided needle localization, we'll perform a specimen radiograph and or a specimen ultrasound to show that the lesion in question was obtained.

Ultrasound Guided Needle Biopsies

Now we're doing ultrasound guided needle biopsies in many instances these days because surgical biopsy is quite traumatic, so we'd like to avoid that whenever possible.

And ultrasound guided procedures are relatively quick and fairly less traumatic than an open biopsy.

Patient Scheduling and Preparation

When a patient is scheduled for needle biopsy, generally at scheduling, the scheduler will ask her a number of questions, probably the most important of which is whether or not she has any kind of bleeding disorder, and that can be due to anticoagulant administration, such as the use of aspirin or coumadin or other metabolic reasons for bleeding abnormalities.

At this point, if the patient does have some kind of bleeding problem, the physician will be notified and generally will contact the patient's physician and work out the problem.

At the time of the biopsy, it's a good idea to ask the patient about any allergies or sensitivities, particularly to the drugs that you may be administrating, such as lidocaine or epinephrine, and sometimes even iodine.

The patient may be sensitive to iodine, and I have had patients sensitive to tape as well, and you might wanna avoid the use of tape.

Then we'll sit down with the patient and describe the procedure.

Ideally you should also be describing alternative methods for biopsy, but most importantly, you wanna describe what kind of complications could arise, and that generally is in the form of some kind of hemorrhage.

Could be contusion, black and blue marks, or hematomas, usually fairly small, but you want to warn her that sometimes they can be rather large.

Rarely would they have to go to surgery to have that fixed. Infection is rare. It's a sterile procedure.

Pneumothorax hopefully isn't going to be a problem, so it's gonna be watching that needle with your ultrasound transducer.

But you can let her know that she'll probably have some discomfort after the procedure for a week or so.

And then don't forget to let the patient ask questions about the procedure.

Then I'll pre-scan the patient and determine how I wanna approach the lesion.

And this may mean that I'll go to the other side of the patient, or maybe sometimes even turn the patient around so that her feet are toward the ultrasound machine rather than her head.

The idea is to find the most comfortable way of localizing the lesion for you.

Another reason to pre-scan the patient is to try to get some idea of how dense her tissue may be before you put a needle in it.

Usually I'll have the patient in the same position that we've done the diagnostic study in.

She'll be supine or supine oblique with the ipsilateral arm raised up over her head.

You can put a little wedge or rolled up towel under her shoulder so she can stay in that supine oblique position.

But again, I'll change that position of the patient, or I'll change my position relative to the patient so that we can either see the lesion better, so that the approach is less awkward or to immobilize the mass better.

And in patients with large floppy breasts, I'll even have the technologist who's helping me out hold the breast steady.

Or sometimes I've taped the breast down.

Remember to make the patient comfortable as well.

And sometimes placing a pillow under her arm or her legs may help her stay in position more comfortably longer.

And this is a picture of a woman where her arm is down at her side, she's lying flat on her back.

And her breast, if we were to examine it, would be fairly soft mobile.

And generally more difficult to keep a lesion immobilized to place a needle into it or through it.

But if you roll the patient up a little bit and put her arm up over her head, the breast tissue evens out over her chest wall stretches out and becomes a firmer piece of tissue for you to work with.

Preparing the Field and Anesthesia

When you prepare the field for biopsy will generally be using iodine solution to cleanse the skin.

Sterile drape is helpful to keep the area clean.

We generally use a sterile probe over the transducer to keep both the patient clean and to keep the probe from becoming dirty.

And we'll use sterile gel or iodine as a coupling agent.

To anesthetize the patient, we'll use a 25 gauge needle and 1% lidocaine for deeper lesions.

And for lesions where we'll be performing core biopsy, we commonly administer lidocaine with epinephrine, and the epinephrine should cause some constriction of blood vessels and hopefully a little less bleeding.

You can also add bicarb to your lidocaine solution, which takes the sting away a little bit.

Then we can deliver an amount of anesthetic that is appropriate for the procedure that's being performed.

I generally give just a little bit if I'm doing a quick cyst aspiration, but I'll give more all around underneath and above the lesion if I'm going to be doing a core biopsy.

Biopsy Approach and Visualization

When we set up to do the biopsy, we'll wanna use what I call a longitudinal approach to get the needle into the lesion.

And what we'll want to remember is that we wanna follow the course of the needle with our ultrasound transducer from the skin all the way into the mass.

And the way we do that is to place the needle at the edge of the transducer, advance the needle just under the skin.

And at that point, you should be able to see the needle at the edge of the transducer.

And then you can advance the needle under the ultrasound beam into the mass.

And if you do that perfectly, you'll have a nice longitudinal look at the needle going into the mass.

What we don't want to do is the transverse approach, where we place the needle along the long axis of the transducer and then advance the needle.

And the reason for this is you're guessing as to the angle that the needle has to be set to reach the mass.

And we generally only see a cross section of it.

And this is an example of how the needle just missed the mass using this transverse approach.

So the ideal needle placement again is placing the needle at the edge of the transducer and advancing it so that the needle stays within the ultrasound beam and meets the mass.

And if you look down at your hands, you'll see that the needle is directly underneath the short edge of the transducer.

Now, it's not uncommon that the transducer may move a little bit.

Perhaps you're keeping a good eye on the mass, and then you move your needle and then all of a sudden you can't see the needle.

Well, there is a way to find it again, and that is to look down at your hands.

Don't move anything, just look down at your hands, keep the transducer steady, and then torque the needle so that it is again immediately beneath the ultrasound beam, immediately beneath the transducer, parallel to the transducer.

And then you might be doing just a wonderful job of advancing the needle and watching its course.

But again, you may slip and slip off of the mass so that you see the needle, but you may not see the mass.

So to get out of this predicament, what you can do is just stop, twist the transducer enough to get the mass back into place.

And again, look down at your hands and torque the needle underneath the transducer so that it's parallel to the beam, and so that you can see the entire length of the needle as it's again coursing toward the mass.

Another thing to remember is that linear objects produce brighter echoes if they are perpendicular to the ultrasound beam rather than at an angle.

So this is an example of a 25 gauge needle in a phantom at about a 45 degree angle to the ultrasound beam.

We can see the tip of it very well, but we don't see the shaft of the needle well at all.

But here at a shallower angle, it's much better seen and at an even shallower angle, it's creating so much echo that it's reverberating, so that's very easily seeing.

So try to remember that you wanna come in at a fairly shallow angle, if you can, to be able to see that needle well.

Types of Ultrasound Guided Biopsies

So there are a number of types of biopsies that we perform, including cyst aspiration, fine needle aspiration biopsy of solid masses, and automated throw core biopsies and vacuum assisted core biopsies of solid masses.

Cyst Aspiration

Indications for ultrasound guided cyst aspiration may include patients who are symptomatic, where the cyst is not palpable.

Symptomatic generally means that they're having pain relative to the cyst.

A palpable, painful cyst might be aspirated by the patient's physician himself without the need for ultrasound in patients who have implants.

Whether the lesion is palpable or not.

Generally we're asked to perform ultrasound guidance because we don't wanna put the needle through the implant cysts that are complex, and we'll talk about those a little bit later.

May require aspiration and will perform aspiration on any cyst if the physician and or patient has requested it.

The American College of Radiology has defined simple cysts, complicated cysts, and complex cysts, and using birads lexicon will want to sort those out.

Simple cysts generally are benign, and we leave them alone.

Complicated cysts are very common, and they also tend to be benign, whereas complex cysts are more likely the ones that require sampling.

Simple cysts are anechoic, have well circumscribed margins, and may have one or two thin septations and generally good posterior acoustic enhancement.

And this is an example of what we would consider a simple cyst.

It has a couple of thin septations, it's well circumscribed, it has posterior acoustic enhancement.

There's a smaller simple cyst next to it.

This is not something that we would recommend aspiration for, but of course, if the patient or physician would prefer it aspirated, it can be done.

A complicated cyst has internal echoes, which are generally homogeneous and scattered and may actually be floating on real time evaluation.

A complex cyst, on the other hand, has a more solid appearance to its internal echoes.

It may have intraluminal projections.

Masses within the lumen itself may have thick septations or irregular margins of its wall.

Complicated cysts are fairly common, particularly in patients who have lots of cysts that come and go.

And most of the time we don't aspirate these, exceptions might be that solitary complicated appearing cyst in a breast with multiple simple cysts, or a solitary cyst without other cysts around, however, if it's the only complicated cyst that we see, and we definitely see floating debris, particularly if it looks like cholesterol crystals with ring down artifact, it does not need aspiration.

So in patients with multiple complicated cysts, we'll tend to follow them.

And some of these may actually appear solid due to inspissated material.

But again, most complicated cysts are seen in patients with multiple cysts in varying states of complexity, and we generally leave them alone.

This is an example of a complicated cyst with cholesterol crystals that are floating around inside.

You can see them move on real time evaluation, and you can also see some ring down artifact from them.

Now here are a couple of simple cysts, and between the two is what I would call a complicated cyst.

It almost looks solid, but knowing that she has multiple cysts in her breast, there are others that have echoes within them.

This is most likely a benign cyst.

It's also well circumscribed. It has an oval appearance.

It's benign in appearance.

This is not something that we would tend to want to aspirate.

On the other hand, this is a cyst containing a mural nodule.

There is a solid mass within the cyst.

This is something that would require biopsy, and we have to be very careful about what we call cysts.

This is an anechoic mass with posterior acoustic enhancement, but its margins are very irregular.

And this should clue us in to the fact that it is not a simple cyst and requires some kind of biopsy.

You could start with a cyst aspiration, but when you get no aspirate, then you may wanna move on to core biopsy.

This actually was an invasive ductal carcinoma.

For cyst aspirations we can use anything from a 25 to 18 gauge needle.

For a simple cyst, which is fairly small, go ahead and put in a 25 gauge needle.

You don't even really need lidocaine to do that if it's a large cyst.

However, you'll be there for quite a while trying to remove all of the fluid.

With a 25 gauge needle, most of the time we'll use a 20 cc syringe.

But if you suspect that the cyst is complicated with a lot of debris within it, then you may have to go to an 18 gauge needle and use a fair amount of suction.

And occasionally what you'll get is material that looks like toothpaste, very, very thick.

This is an example of a simple cyst, which was aspirated with a small gauge needle.

And we can see that post aspiration there's nothing left.

On the other hand, this is a mass, which was in a patient with a lot of other cysts, and this required an 18 gauge needle before we were able to pull out some of this very thick debris.

And on post aspiration, we see that we did make the mass decrease in size somewhat.

What do you do with the fluid once you remove it?

Well, a lot of times we'll just throw it away.

There is some controversy about that, whether we send all aspirate to cytology, we don't send any aspirate to cytology, or do we only send suspicious aspirate.

In one study by Seattle in 1987, he looked at over 6,000 consecutive aspirates.

Most of those were not bloody.

All of them had negative cytology and no malignancies were found.

Now, if we see bright red blood in our aspirate, we know that that was a traumatic aspirate, and that's not really something that we have to worry about.

But if you see dark blood or old blood, then that raises the suspicion for an intracystic tumor, which is most likely going to be a papilloma.

In Seattle's study of 125 bloody aspirates, five of them were papillomas.

Intracystic carcinomas are rare.

They make up about 0.1% of palpable cysts, and 0.5 to 2% of all cancers.

If you get dark blood from your aspirate, it's a good idea to recommend excisional biopsy right then and there with or without positive cytology results.

It's very possible to get old blood out, but miss abnormal cells, so those should all be excised.

If you aspirate a mass to completion and you get what you think is dark blood out of it, and you cannot see any evidence of that mass after you've aspirated, then you have to check for recurrence.

And generally we'll bring the patient back within a month, and if we can't find it, then we'll bring her back in another three months.

But if it recurs, we should excise it.

Now, for non-bloody cysts that recur, we generally don't have to do anything with those cysts as long as the patient remains asymptomatic.

Fine Needle Aspiration Biopsy

Fine needle aspiration biopsy is something that is quite quick to perform.

It's, it causes very little trauma.

And ideally it would be what we would want to do for a very quick diagnosis of a mass that we see.

Unfortunately, insufficient sampling is a problem, and it very much depends on both the skill of the radiologist performing the sampling and the cytologist evaluating the results.

Up to 20% of fibroadenomas may give a dry aspirate.

So sampling fibroadenomas is probably not a good idea if you want a definitive answer.

And the sensitivity for identifying cancers is only about 90%.

If you want to do fine needle aspiration biopsy, generally I would give a small amount of anesthetic and we'll use a 25 to 22 gauge needle.

We place the needle into the mass and we sample by twisting the needle and advancing and pulling back with this two and fro motion.

There's some advocates for using suction with the biopsy and some prefer no suction.

You can be in that mass for quite a period of time, you know, 20 or 30 seconds taking your sample.

And if you're in there for that amount of time, then one pass is usually all that you really need.

If you're going to do fine needle aspiration, it's very helpful if a cytologist is present to help you determine whether you obtain an adequate sample or not.

If you're sending the slides out for evaluation, you have to learn how to prepare the slides appropriately.

Generally, we smear the sample and spray it with a fixative or place it in formalin.

And we'll also place some of the material in a tube for cell block evaluation.

If you want to try to get estrogen receptors on suspected cancers from your fine needle aspirate, then discuss with the cytologist, how they would like that prepared.

And this is an example of what we would do with fine needle aspiration.

Get that needle in there back and forth, up and down.

And this is an example of what this needle would look like in the mass.

Core Biopsy

Now core biopsy certainly has its advantages over fine needle aspiration.

We get a fair amount of tissue from core biopsy.

We can commonly determine whether a malignancy is invasive or in situ to core biopsy is less dependent on both the skill of the radiologist or pathologist relative to fine needle aspiration.

It's less expensive than surgery.

It's less traumatic than surgery, unfortunately, it's more traumatic than fine needle aspiration, but we get a result.

Generally, it does increase potential for complications including hematoma in particular.

And we do have to be aware that we may not sample the lesion in total, so that we could miss something.

Significant indications for ultrasound guided core biopsy are finding a mass on ultrasound, and sometimes we'll biopsy calcifications on ultrasound if they are visible.

Occasionally a patient will ask for core biopsy over surgery to lessen the degree of trauma.

And a lot of times the physicians would prefer ultrasound guided biopsy over stereotactic biopsy.

If we're trying to decide which core biopsy method is appropriate.

Ultrasound is faster and a little bit easier on the patient than stereotactic biopsy.

For masses that are very posterior or very anterior stereotactic biopsy can be difficult and ultrasound guidance much easier.

Also, patients who cannot tolerate positioning for stereotactic biopsy do much better with ultrasound guided biopsy.

When we are preparing to do the biopsy, we wanna consider the location of the mass.

And even though the nick is fairly small, particularly relative to a surgical biopsy, I prefer to hide it along the edge of the areola.

If we place the skin nick distant from the areola, then you might wanna consider that the best placement is along the contour lines or along longer lines.

These give a slightly more acceptable scar, and they tend to be parallel to the areola.

Biopsy Devices

There are a couple of different biopsy devices that we can use.

The automated throw devices are very common and they come in throwaway style, or you can use reusable guns.

There are long throw guns and there are short throw guns.

The long throw guns are generally what we use, but the short throw guns might be helpful in lesions that are very close to the chest wall.

The common size is 10 centimeters in length, and 14 gauge.

These tend to be more cohesive or they give more cohesive samples than smaller needles, such as 18 and 20 gauge.

So standard for automated throw at this point is about 14 gauge, but more and more we're using vacuum assisted mammotome devices.

And the needle gauge for these are on the range of 8 to 14 gauge.

The larger bore needles can be used to even remove benign masses, such as fibroadenomas.

The advantages over the automated throw devices are that you have to position them once only and they give larger samples.

The disadvantages are, they are more traumatic and they are more costly.

Automated Throw Core Biopsy Technique

When we use the automated throw devices, we generally like to use coaxial technique that allows the single introduction of an outer sheath, and then you can place the cutting needle through that cannula multiple times without causing increased trauma to the breast.

And this is a little diagram of how we place the needle through the cannula.

When we fire the gun, the needle pops out, you can see there's a little bevel there.

The tissue would fall into the bevel, and then very quickly, a cutting edge comes out, cuts the tissue and traps it in the needle.

We discussed the longitudinal approach for positioning the needle before we wanna see the entire length of that needle before we fire the gun, because we have to determine where the needle will end up when we fire the gun.

And you have to remember, it's about a 2.5 centimeter throw.

So we have to imagine the course of that needle when you fire the gun so that you don't hit anything you don't wanna hit, such as the chest wall.

Ideally, you'd like to place your needle parallel to the chest wall one, you can see the needle best that way, and you can avoid trauma to the chest wall or avoid pneumothorax.

And this ideally is what we would want to see.

However, if you have to come a little closer to the needle, you just have to be very careful about that throw because you don't want to place it into the chest wall.

And here is a real example of a mass very parallel to the chest wall, as well as parallel to the ultrasound transducer.

You can see the needle very well, and you can see it go into the mass and it avoids the chest wall.

And here we have number two fire.

And I like to document every fire that I do so that I know where that needle ends up and that I know that we've gone through the mass a number of times.

We can do this technique even in patients with implants, as long as we're very careful to keep that needle parallel to the chest wall and parallel to the implant.

Now, sometimes the needle's just not long enough to place it parallel to the chest wall, and we have to do something a little more creative.

Remember that the breast itself is very malleable, and we can use that needle as a lever in the breast because the breast is mobile.

So rather than starting way far away from the mass, we can bring that needle up and start very close to the edge of the transducer.

We place the needle almost straight down into the breast, being careful not to go to the chest wall.

And then we'll torque it.

And while we torque it, we can actually raise the tissue, including the mass.

And when we fire the needle, then we can avoid the chest wall.

And here's a real time example. We have the needle.

We've placed the needle just under the mass.

We've torqued it so that we've lifted the mass up.

We even torque the needle more so that it was parallel to the chest wall and fired it.

And you can see how nice and parallel the needle is relative to the chest wall through the mass.

And this is an example just showing sometimes how much you have to press down on the hub of the needle.

We actually lose a little bit of the skin line there because we're pressing down on it.

For core biopsies, I usually do at least three passes and usually more, you wanna just make sure that you've been through that mass at least three times and gotten a good sample from it.

I always document needle position, both before the firing of the gun and afterward.

And it's not a bad idea to look at the needle after you've fired it in both the longitudinal and transverse projections to make sure that the needle actually has gone through the mass.

Then we'll take the specimen.

If there are calcifications, we'll radiograph it and make sure that we got them.

And then we'll place it in formalin.

Vacuum Assisted Core Biopsy Technique

This is an example of a vacuum assisted device.

It's the mammotome. This is the atec device.

This is the one that we are using right now.

You can see that the needle itself is rather large bore.

This is 12 gauge, and there is a bevel at the end of the needle.

The other end has a collection chamber.

And with these vacuum assisted devices, the needle collects the tissue and sends it out into the collection chamber.

So you don't have to remove the needle and then place it again as you do with the automated throw type devices.

And this is a phantom showing what a vacuum assisted device looks like as it's actually taking a slice of tissue.

And here's a transverse image of the phantom showing a hole that the device has made.

So it's a fairly good size piece of tissue that it can take.

After you take your biopsy, and generally, what we'll do is take an image of the mass with the needle in place, and then we'll take several pieces of tissue.

And after the biopsy, we will then place a clip and document clip placement.

If malignant, the clip is extremely helpful to mark the site of biopsy for future imaging.

It marks the site of the tumor.

If the patient goes on chemotherapy and the mass does respond to chemotherapy, there may not be much mass left when it comes time to do the patient's lumpectomy.

So the clip is there marking the site of the malignancy.

If benign and a clip is in place, then we know in the future on mammography that that mass does not have to be evaluated again with biopsy 'cause we've already been there.

And there are a number of marking clips that you'll see out there.

All of them work very well.

They all look a little different both on ultrasound and on mammographic images.

After the biopsy, I like to obtain a mammogram showing the location of the clip.

That helps us see where the mass is on mammography, or if for some reason I think the clip has been dislodged perhaps during removal of the needle, then we can document it and try to determine how far from the mass the needle really is and document it on the films as well.

The advantages to using the automated throw devices again are less traumatic and they're less expensive.

They are harder to use to obtain adequate calcification samples, and there is probably a greater risk of under sampling of a lesion.

The vacuum assisted devices really are faster to obtain the tissue needed.

They give larger cores, which the pathologists enjoy.

It's easier to get calcifications and you probably get more complete sampling easier.

And in fact, you may actually remove the entire lesion fairly easily if the lesion is small.

But it is more expensive and it is more traumatic than the automated throw devices.

This just shows you how large some of these samples can be relative to the more usual 14 gauge automated throw type samples.

Potential Problems in Core Biopsy

We do have to be aware of some problems that may come up with core biopsy.

Once in a while when you're delivering your anesthetic, you may absolutely obscure the lesion by placing this fluid in the breast.

So we have to be very careful about watching the mass as we are delivering anesthetic.

And if we really can't see it after we've delivered that anesthetic, we have to cancel the biopsy.

Once in a while, the mass may be quite movable in the breast, and we have to do our best to immobilize it.

This is when you might wanna have somebody actually hold the breast taut or tape it down somehow.

For masses that are very small, it is possible to obliterate the lesion.

And this is one reason why you want to place a clip after you've performed your biopsy.

And we have had instances where we've performed a biopsy, gotten a cancer, and then gone to do a lumpectomy, but couldn't find the lesion either mammographically or by ultrasound.

Now, we may actually have removed it in its entirety, but we certainly haven't performed a therapeutic core biopsy.

She needs the lumpectomy.

If you can't see it, it's difficult to perform an adequate lumpectomy.

So placing a clip is very helpful.

And we also again have to remember that we may only sample a small portion of the mass, so we might miss a small focus of malignancy.

Handling Results and High-Risk Lesions

Now, there are a number of high risk lesions that we have to watch for, and if we obtain them, we generally go right back and perform an excision.

Atypical ductal hyperplasia is one of them.

Now, stereotactic biopsy is usually performed for calcifications and with a 14 gauge mammotome device.

It has been reported that 50 to 56% of biopsies showing ADH will prove to be malignant when excision is performed.

DCIS is the most common malignancy obtained at excision, but all ADH cases will go to re-excision.

Ultrasound guided biopsies using 14 to 11 gauge vacuum assisted core biopsies have a much lower rate of malignancy when ADH is obtained.

This is usually because we're biopsying masses rather than calcifications on ultrasound.

And we know when we get a pretty good sampling of the mass, so only 4% turn out to be malignant.

But all ADH cases, nevertheless, should go on to excision.

Radial scar may be upgraded to malignancy in two to 50% of cases in a review of the literature from 2003.

So generally, we will recommend that radial scars when biopsied be removed completely.

Fibroadenoma tumor and is a potentially malignant lesion.

So if we do obtain a phyllodes tumor at core biopsy, that lesion should be completely excised.

There is some controversy about what to do with lobular carcinoma in situ too, but the more recent literature suggests that there is a fairly high upgrade to malignancy 18 to 50%.

And so these days, LCIS will go on to excision.

There's also some controversy for papillary lesions and a 2006 report by Mercado.

21% of benign papillary lesions at core biopsy were upgraded to either ADH or DCIS.

So many physicians will recommend that any papillary lesion be removed completely.

For DCIS obtained a core biopsy, a fair number of those will also be upgraded to invasive malignancy.

Of course, all DCIS cases will go on to lumpectomy.

Now, if we have a discordance between our imaging findings and histology, meaning our imaging looks quite malignant, and our histology at core biopsy is benign, we will commonly go back and rebiopsy and zero to 64% of discordance cases will result in malignancies at excision.

Other Interventional Procedures

There are a number of other interventional procedures that may be performed using ultrasound guidance.

Abscess drainage is one of them, and we can either do that simply by placing a large gauge needle in the abscess if it's small enough, or we can place drainage catheters under ultrasound and drain them in that way, thereby avoiding an open drainage in the operating room.

Fine needle aspiration biopsy has been described after performing galactograms, and I've even performed galactograms using ultrasound guidance to place the needle in dilated ducts.

And this is a recent case that I did with a vacuum assisted device patient who had had a mastectomy, and she had a very uncomfortable chronic septated collection in her chest wall.

And this actually was very longstanding.

It had been aspirated a number of times, but because of all the septations within it, a very limited aspiration could be performed.

We placed the vacuum assisted device within it and removed about 300 ccs of material and fluid.

Unfortunately, it recurred within a couple of weeks.

The next thing we did then was place the vacuum assisted device in and actually kind of roughened up the wall of the collection in a number of places and aspirated it to almost completion.

At that point, it did recur, but not to the extent where it caused her discomfort as it had before.

So, roughening up the wall did seem to have some kind of therapeutic result in this patient.

And we also had placed a drainage catheter in her as well.

And this is just an ultrasound image of that.

Post-Procedure Care

Well, after a biopsy, we will manually compress the breast.

After automated throw sampling, I'll compress the breast with one hand and remove the needle with the other, and have my assistant remove the sample from the bevel of the needle, and then place it right back in through the coaxial sheath and take another piece of tissue.

Once we're done with the entire procedure, we'll compress until she's done bleeding.

Put a little steri strip over the nick, and commonly put a pressure dressing.

After the entire procedure is completed, after her mammogram is done, we'll give them a little ice pack.

Tell them make sure not to place that ice pack on the breast for not more than about 10 minutes at a time.

We ask them to avoid strenuous activity for 24 hours and watch for re-bleeding, pain, and fever.

Summary

So, in summary, when we're performing procedures, we'll want to discuss the procedure very well with the patient and let her know what's coming and what she can expect after the procedure.

We wanna plan our approach very carefully, so that it's comfortable for you to perform, and it's also comfortable as possible for the patient to undergo.

We wanna remember that we wanna see the entire length of that needle during our entire biopsy.

Placing a clip following the biopsy is very helpful for future use, and we have to be very thoughtful about the results that we obtained from pathology to manage the case appropriately.