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Minimally Invasive Breast
Procedures
F. Sperber, M.D.
Breast Imaging Center
Sourasky Medical Center
Tel Aviv University
Percutaneous core breast
biopsy - Advantages
► Since
a few years ago most of the suspicious
clinical or mammographic lesions were diagnosed
by surgical biopsy.
► With time percutaneous core biopsy proved to be
efficacy in the diagnosis of breast lesions.
► Is faster, less expensive than surgical biopsy.
► Less tissue is removed resulting in no deformity or
scaring.
Percutaneous core biopsyAdvantages
 Spare surgery in benign lesions (60% of the
mammographic findings).
 Reduce the number of surgical procedures in
cases of breast cancer, providing surgery
planning.
 Lumpectomy and sentinel node or axillary
dissection as one step procedure in malignant
cases.
 Mastectomy in cases of multifocal-multicentric
lesions.
Guidance modalities
► Stereotactic
mammographic guidance
► Ultrasound guidance
► MRI guidance
Stereotactic mammographic
guidance
 Stereotactic units are available in two different
configurations :
-Add -on units attached to mammography units
(sitting position).
-Dedicated prone tables ( lying position).
 Selection of equipment is based on considerations
of cost, patient volume and space availability.
Stereotactic mammographic guided
Mammographic Guided BiopsyStereotactic Table
Stereotactic mammographic guided
Advantages
Patient motion is eliminated
Patient don’t see the biopsy
less
vasovagal reactions
Disadvantages:
Space
Difficult access to lesions close to the chest
wall
Stereotactic mammographic
guidance: Technique
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Enables a lesion to be localized
three-dimensionally trough the
used of angled images.
Localization is done by
identifying the site of the lesion
in x-axis, y-axis and z-axis.
The depth of the lesion (z-axis)
is calculated by the shift of the
lesion along the x-axis when
the tube is tilted in this plane.
Standard equally angled views
of 150 are used to calculate the
location of the lesion.
Accuracy in performing the
biopsy is dependent on the
accurate localization of the
same point in the lesion on
angled views.
Mammographic guided
Ultrasound guidance
One of the most important applications of breast
ultrasound is to guide interventional procedure
► Most common used technique.
Advantages:
► Non-ionizing radiation.
► Accessibility to all parts of the breast and axilla.
► Quicker and no discomfort (no breast
compression).
► Real time visualization of the needle providing
accuracy of the targeting.
► Low cost.
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Ultrasound guidance
Disadvantages
Most difficult technique to perform.
Requires long time of expertise.
Slow learning curve.
MRI guided
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Always performed after
second look ultrasound
(fails in > 77%).
MRI compatible devices.
► Biopsy is performed
outside the magnet.
► Coaxial sheath:
Inner stylet
Outer cannula
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Biopsy Procedure
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Fiducial Marker: Small plastic
capsule filled with saline and
gadolinium or oil.
Calculation of x,y,z
MRI moved out and the needle
guide is adjusted
Lidocaine injection
Coaxial sheath is inserted, inner
stylet is removed
MRI table is returned to the
magnet
Limited axial sequence is
performed
Site clip
MRI biopsy guidance
Tissue Acquisition Devices - Types
and Indications
► FNA
( Fine –needle aspiration)
► Core biopsy
► Vacuum assisted core biopsy
► Fine needle localization devices
Minimally Invasive Procedures Types &
Indications
►FNA
►Core
►Cysts,
Needle Biopsy
►Drainage
of
Core Needle Biopsy
(Mammotome)
masses
►Abscess
and post
surgical collections
►Pre-Operative
collections
►Fine Needle
Localization
►Vacuum-Assisted
►Solid
Lymph nodes
Large
►Solid
masses smaller
than 5mm and
calcifications
FINE NEEDLE ASPIRATION
Most popular technique of biopsy for breast
palpable and nonpalpable lesions.
ADVANTAGES
Virtually atraumatic
Rare to even cause a hematoma
Simple to perform
DISADVANTAGES
Extremely dependent on level of cytological interpretation.
High percentage of insufficient, material aspirates (34%-40%).
Cytology doesn’t differentiate between in situ from invasive
disease
TECHNIQUE-EQUIPMENT
► 10-20-30
ml LUER-LOK syringe
► 21-23-25G needles
► Needle length 3.6-7.8cm
► Glass slides
► 95% alcohol fixative
► Anesthesia is optional
ASPIRATION TECHNIQUE
► After
placement of needle, a syringe is
connected.
► Suction is applied by pulling the plunge
of the syringe.
► Sampling needle should be moved back
and forth rapidly within lesion.
► Needle is angled in multiple directions.
TECHNIQUE FOR F.N.A.
► Vertical
or oblique
needle insertion.
► Needle should be
oriented
perpendicularly to
ultrasonic beam.
► Needle shaft and
tip should be
visualized during
procedure.
FINE NEEDLE ASPIRATION
Pre-FNA
Post-FNA
LYMPH NODE F.N.A.
CORE NEEDLE BIOPSY - CNB
► First
described in 1982 by Perlinggren,
Sweden.
► Cutting needle fits in automated springloaded biopsy gun.
► Most accurate results with 14-gauge.
► Needle consists of inner tissue sampling
needle and outer cutting needle.
CORE NEEDLE BIOPSY - CNB
17mm tissue slot is located
4mm from end of inner
needle.
► Prebiopsy position , outer
needle covers inner
needle.
Throw short &
► Inner needle long
is advanced
(15/22mm)
forward, moving tissue
slot within lesion.
► Outer needle slides over
inner needle, cutting a
tissue sample and securing
it in slot.
Throw short &
long (15/22mm)
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Trigger
Safety device
DISPOSABLE SEMIAUTOMATIC
BIOPSY NEEDLE
Stylet
Hub
Main part
Plunger
CNB - TECHNIQUE
► Patient
in supine position.
► Skin disinfection with alcohol or polydine.
► Probe is disinfected with alcohol
► Probe may be covered with sterile plastic
sheath.
► Sterile gel or alcohol should be used as
coupling agent.
► Local anesthesia.
► Skin incision, 2-3mm.
Needle placement with ultrasound
guidance - TECHNIQUE
► Transducer
is placed
on patient’s skin so
both lesion and path
of needle are visible.
► Needle position is
documented with
longitudinal and
transverse scans.
Ultrasound guidance-Technique
Core Sampling
►5
or more cores require reinsertion and
repositioning of needle.
► Visual inspection of samples.
CNB - TECHNIQUE
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Specimen placed in
formalin and sent for
histological
diagnosis.
5-10 minutes
compression.
Bandaging applied.
Advantages of Core Biopsy
► 96%-100%
concordance between CNB
and surgery.
► No insufficient samples.
► Histological tissue diagnosis allows
differentiation of IDC from DCIS.
Disadvantages of Core Biopsy
► Multiple
insertions and removal of the needle.
► Later samples composed predominantly of
blood.
► May be nondiagnostic in small lesions
► Retrieval of calcifications is difficult
► Incomplete characterization of ADH
and DCIS
COMPLICATIONS AND RISKS
► Fainting.
► Hematoma
6-30%.
► Seeding of needle track by malignant
cells.
Vacuum-Assisted
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Mammotome
Histology
Large, contiguous tissue samples
Less precise targeting required
because of vacuum assistance
Ability to place a marker at the biopsy site
Sutureless
Single insertion
Vacuum-Assisted Biopsy:
Advantages
► Suction
of the blood out of the biopsy
cavity.
► Only one insertion of the needle.
► Larger specimen- 11G or 8G.
Vacuum-Assisted Biopsy:
Advantages
 Significant improvement in the retrieval of
calcifications
Vaccum assisted biopsy:
Advantages
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Clip Placement
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More accurate characterization of ADH and DCIS,
DCIS and IDC.
Reduction in the underestimation of ADH and
DCIS comparatively to core biopsy.
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NEEDLE LOCALIZATION FOR BREAST
EXCISIONAL BIOPSY- F.N.L.
► Designed
to direct the surgeon to
appropriate site within breast, insuring
accurate removal of suspicious lesion.
► Less commonly used for diagnostic
purposes – only when accurate needle
sampling was not achieved
HOOKWIRE SYSTEMS
HOOKWIRE SYSTEMS
Mammographic Fine Needle
Localization
Sonografic Fine Needle
Localization
EXCISED SPECIMEN
Two-view magnified
specimen
radiograph.
US specimen in masses
visualized
sonographically
Minimally invasive technique in Breast
Cancer Treatment: The Future
► Stereotactic
excision with vaccum assisted
core biopsy
► Criotheraphy monitored by ultrasound
► Laser ablation/focused ultrasound
► Radiofrequency monitored by ultrasound
Cryotheraphy
► Advantages
Is easy visualized
with ultrasound.
- Painless.
- Can be used for
masses near the
skin.
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Intracellular Ice Formation
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Very high freezing rates
 Within a few millimeters of the cryoprobe
 Ice crystals cause mechanical injury to cellular
organelles and membranes.
Extracellular Ice Formation
► Solution
Effects
-Majority of iceball experiences lower freezing rates
-Ice formed outside the cell – hyperosmolarity.
-Osmotic dehydration and shrinkage of the cell.
-Damage to enzymatic machinery, destabilization of cell
membranes.
Delayed Ischemic Damage
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Dominant killing mechanism results in uniform
necrosis.
Endothelial cells comprising the microvasculature
are very susceptible to direct damage.
Microvasculature endothelial destruction results
in post-thaw platelet aggregation and subsequent
vascular stasis.
Within hours and days following cryoablation
ischemic damage occurs throughout the
previously frozen volume.
Conclusions
► Minimal
invasive procedures became 1/3 of the
diagnostic work in breast imaging.
► Team work approach is essential for further
management of the breast cancer patient.
► The traditional approach to surgical margins may
be replaced in the very near future by minimally
invasive treatment techniques of the primary
tumor.