Prebiopsy Patient Workup

Nonpalpable, imaging-detected breast lesions are amenable to preoperative localization and surgical or percutaneous needle biopsy. The decision whether to operate or do a needle biopsy to make a diagnosis requires communication between the surgeon, patient, and radiologist to determine the correct approach. There is a strong progressive trend toward using needle biopsy to diagnose nonpalpable breast lesions whenever possible, reserving breast surgery for therapy.

Nothing substitutes for complete imaging workup of nonpalpable breast lesions. The radiologist must have the lesion’s location within the breast firmly entrenched in his or her mind to plan an approach that will be successful in biopsying the lesion with safety and accuracy. For mammography, this means visualization of the lesion in craniocaudal and mediolateral orthogonal views (Box 6-1). When the finding is not seen definitively in craniocaudal (CC) and mediolateral views, the radiologist locates the lesion with fine-detail mammographic views, views with skin markers, triangulation, stereotactic targeting, ultrasound, and physical examination. This is to make sure the lesion is real and to determine its location in the breast. For ultrasound, this means the lesion is visualized on orthogonal scans. Do not attempt to biopsy a breast lesion if you do not know whether it is real or if you do not know its location in the breast!

Suboptimal workup results in procedure cancellation. Philpotts and colleagues reported various reasons for cancellation of stereotactic biopsy in 16% of cases examined (89/572). Canceled procedures and lost time would have been avoided by a full workup or accurate clinical history in most of these cases. With improved workup and advanced biopsy technique, Jackman and Marzoni reported cancellation of stereotactic biopsy in only 2% (29/1809) of cases.

Some calcifications prompting biopsy may be within the skin and not require biopsy at all. Peripheral location of calcifications and radiolucent calcification centers may be clues to a skin location for calcifications. Tangential views can then identify dermal calcifications, and the procedure can be canceled.

For a nonpalpable lesion to be biopsied with safety and accuracy, the patient must be able to cooperate and hold still during the procedure, have no allergies to medications used during the procedure, be able to follow postbiopsy instructions to diminish bleeding and other complications, and be compliant with postbiopsy follow-up (see Box 6-1).

Informed Consent

Informed consent is an important part of any procedure (Box 6-2). For percutaneous needle biopsy, the radiologist informs the patient of the risks, benefits, and alternatives to percutaneous biopsy (e.g., surgical biopsy), as well as the risks and benefits of any alternatives. The most common complication after core or vacuum needle biopsy is hematoma formation, but it is rarely significant. Other rare complications include untoward bleeding (very rarely requiring surgical intervention), infection (with mastitis very rare), pneumothorax, pseudoaneurysm formation, implant rupture, milk fistula (if the patient is pregnant or nursing), and vasovagal reactions (see Box 6-2). The patient is told that later surgical excision will be needed if the biopsy reveals a malignancy, high-risk lesion, or discordant benign lesion, or if the needle biopsy cannot be completed because of technical limitations (see Box 6-2). She is told that the postbiopsy metallic marker may end up in a suboptimal location. The patient is informed about wound management after the biopsy and about when and how to obtain biopsy results.

For preoperative needle localization, the surgeon obtains informed consent for both the needle localization and surgical excision. The radiologist confirms that the patient is properly informed about the needle localization part of the procedure.

Skin Sterilization, Local Anesthesia, and Skin Nicks

The breast skin is sterilized with a cleansing agent, usually alcohol- or iodine-based, before anesthetic needle insertion. Most facilities routinely use local anesthesia for percutaneous needle biopsy and preoperative needle localization. A common local anesthetic for breast biopsies is 1% lidocaine buffered with 8.4% sodium bicarbonate in a 10 : 1 ratio. The lidocaine is given without epinephrine in the skin and subcutaneous tissue (to avoid skin necrosis) and with 1 : 100,000 epinephrine in the deeper tissue (to increase hemostasis and prolong the anesthetic effect). To avoid mix-ups, the two solutions may be drawn up in different-sized syringes, with a 25-gauge skin injection needle placed only on the syringe containing plain lidocaine, and each syringe is labeled with its contents. The maximum dose of 1% lidocaine with epinephrine is 7 mg/kg (3.5 mg/pound) body weight, not to exceed 500 mg. This translates to 50 mL in a 70-kg patient. The maximum dose of 1% lidocaine without epinephrine is 4.5 mg/kg (2 mg/pound), not to exceed 300 mg. This translates to 30 mL in a 70-kg patient.

A small skin nick is usually made with a scalpel to facilitate insertion of the larger needles used for needle biopsy; however, it is usually not needed for insertion of a small biopsy needle or localizing needle used to guide surgical excision.

Preoperative Needle Localization

Preoperative needle localization can be guided by orthogonal radiographic, stereotactic, and ultrasound techniques; these are discussed in this section, along with specimen radiography and pathology correlation.

The intent of preoperative localization is to give the surgeon a “road map” to find the lesion inside the breast and excise it. Because the surgeon sees only breast skin on the patient in the operating room, the surgeon cannot find nonpalpable masses or calcifications that were detected by x-ray or ultrasound. To guide the surgeon to the lesion, the radiologist places a needle into the middle of the lesion under imaging guidance. In some facilities, the radiologist injects a small amount of sterile blue dye through the needle to stain the tissue around the lesion for the surgeon to find in the operating room. The radiologist places a hookwire through the needle and removes the needle, with the hooked end of the wire left near or in the lesion and the other end of the wire sticking out of the skin. The technologist takes orthogonal mammograms for both x-ray– and ultrasound-guided needle localizations with the wire in place to show the relationship of the lesion and the hookwire tip. The radiologist then labels the films for the surgeon, and the patient is sent to the operating room with the films. Various ways can be used to guide the needle into the lesion for this type of procedure, as discussed here.

The surgeon uses the wire and mammograms to guide him or her to the lesion and excises the lesion and hookwire. The excised tissue is called a breast specimen. The technologist radiographs the breast specimen. The radiologist reviews the specimen radiograph to see if the lesion and the entire hookwire (with an intact hook) are included (Fig. 6-1A to G).

Figure 6-1 X-ray–guided needle localization with specimen radiography. Mammograms had shown a marker in the left upper inner quadrant where core biopsy showed ductal carcinoma in situ (DCIS). The patient presented for preoperative needle localization to excise the marker and the DCIS site. A, Enhanced digital lateral mammogram shows an alphanumeric plate placed over the skin closest to the marker (arrow). The marker is at coordinates 1.0/D.5. B, After needle placement, the needle hub overlies the marker at coordinates 1.0/D.5. Because the needle hub overlies the marker and the needle shaft, the needle is traveling straight to the marker. C, A craniocaudal (CC) view with the needle in place shows that the needle shaft is adjacent to the marker (arrow) and the needle tip is lateral to it. A BB was placed at the skin entry site (double arrows). D, The radiologist places a wire through the needle and subsequently removes it, leaving only the hookwire in the breast. The CC mammogram shows the marker (arrow) and the hookwire tip 1 cm lateral to the marker. The stiffened part of the wire shaft (which is thicker than the rest of the wire) (double arrows) is right next to the marker. The surgeon can feel this stiffened part of the wire more easily than the rest of the wire. E, Annotated CC mammogram shows the relative positions of the nipple, wire, hookwire tip 1 cm lateral to the marker, and injected dye. F, Annotated lateral view with the needle in place. Some facilities also obtain a lateral view with the wire in the lateral projection. The surgeon uses the annotated CC and mediolateral mammograms and the wire as a “road map” to the marker in the operating room. G, A specimen radiograph shows inclusion of the hookwire, a transected hookwire tip, the marker, and one calcification. During the operation the surgeon transected the hookwire but sent the hookwire shaft and its tip for radiography. It is essential that the hookwire tip is removed during surgery, because if left in the breast the hookwire tip can travel to other body parts. These findings were reported to the surgeon in the operating room. Pathology showed residual high-grade DCIS despite only one calcification remaining. This demonstrates that DCIS can be present in the postbiopsy site even when all the calcifications are removed by stereotactic biopsy, because DCIS does not always calcify.

A special scenario regarding needle localizations occurs when surgeons use “bracketing” wires to remove a large area of breast tissue (Fig. 6-2), a scenario that happens when the mass or calcifications extend over too wide an area to be localized by one wire. In this situation, the radiologist places two wires in the breast, with one wire at one end of the lesion and the other wire at the other end of the lesion. The “brackets” help the surgeon remove the lesion between the two wires in toto. These “bracketed” breast specimens should include the two wires and the mass or calcifications between them.

Figure 6-2 Bracket localization for a large area of calcifications. A, Suspicious area of calcifications in the left upper outer quadrant (circle) underwent stereotactic core biopsy and showed flat epithelial atypia. No marker was placed after stereotactic biopsy at the outside facility. To remove all of the suspicious calcifications, the surgeon requests a bracket localization, in which wires are placed at the extreme ends of the calcifications to remove all of the tissue between the wire tips. B, Scout mediolateral digital mammogram with an alphanumeric plate shows that the calcifications are at 0.5/C.5 and 2.0/B.3 (arrows). C, Mediolateral mammogram shows the needles in place. D, Craniocaudal (CC) spot mammogram shows the needles on either side of the suspicious calcifications (circled) in the outer aspect of the right breast. Note the BBs at the skin entry of the needles. E, Annotated spot CC mammogram after the wire placement shows the residual calcifications (white arrow), the wire skin entry sites marked by BBs, the location of the hookwire tips and blue dye (arrowheads), a linear wire marker on the areolar border (black arrow), and a marker on the nipple. F, Annotated mediolateral mammogram shows the two wires around the calcifications. Hookwire tips and blue dye are marked by white arrowheads residual calcifications between the wires at the stiffeners are marked by a black arrowhead the linear wire on the areolar border is marked with an arrow. G, The magnified cropped specimen radiograph shows the hookwires, hookwire tips, and the calcifications. This is ductal carcinoma in situ.

Ultrasound Guidance

Real-time hand-held ultrasound units with a small transducer provide guidance for preoperative needle localization for ultrasonographically detected breast lesions (Fig. 6-3). To do the localization, the patient is placed in the supine position and the radiologist plans the needle path to the lesion. The radiologist rolls or angles the patient on the table until the needle path is directed safely away from the chest wall to prevent pneumothorax. Using sterile technique and under direct ultrasound visualization, the radiologist anesthetizes the skin and inserts a longer needle for deep anesthesia, keeping the entire shaft of the needle, the needle tip, and the target in the same plane. The anesthesia needle can be used as a “trial run” to judge the safety of the needle path and the difficulty of needle insertion. Then the radiologist inserts the preoperative localization needle into the lesion under real-time ultrasound guidance. Blue dye, if used, and a hookwire are inserted.

Figure 6-3 Ultrasound-guided needle localization. Craniocaudal (CC) (A) and spot compression mediolateral (ML) (B) mammograms show a mass in the medial portion of the breast that was solid on ultrasound, and excisional biopsy was requested by the patient. C, Ultrasound was used to guide a needle into the mass for preoperative localization; the image shows the needle tip in the middle of the mass. After hookwire deployment, CC (D) and ML (E) mammograms show the hookwire tip in the mass. The films were marked with a white grease pen to show the skin outline and skin entry, and an X was placed on the skin over the mass marked with two BBs. F, The specimen radiograph shows inclusion of the mass and the hookwire. Histologic examination revealed a fibroadenoma.

At this point, some facilities place skin BBs before the postwire localization mammogram is obtained. A skin BB may be placed at the wire skin entry site. In addition, the radiologist may place two skin BBs and an indelible ink X over the skin where the lesion lies for the surgeon to see when the patient arrives in the operating room. The technologist then takes a mammogram with the ultrasound-placed wire within the breast.

In some facilities, radiologists or surgeons perform intraoperative ultrasound to direct the breast biopsy.

Specimen Radiography

The needle localization procedure is not over until the specimen radiograph is taken by the technologist and reviewed by the radiologist. The radiologist reports whether the specimen contains the entire lesion, how far the lesion is away from the specimen edge, if the lesion was transected, and whether the hookwire, hookwire tip, and any markers are included (Box 6-3). The radiologist then calls these findings to the surgeon in the operating room. If the lesion is not in the specimen, the radiologist directs the surgeon to the expected location by using landmarks in the excised tissue and on the mammogram and waits for a second specimen (Fig. 6-4). If subsequent specimen radiographs still do not contain the lesion, the surgeon may close the breast and obtain a mammogram to determine whether the targeted lesion is still in the breast. The mammogram is usually done a few weeks after the biopsy.

Box 6-3 Surgical Breast Specimen Reporting

Specimen includes lesion and any associated markers

Hookwire included

Hookwire tip included

Lesion is at or away from the specimen edge, or is transected

Figure 6-4 Importance of specimen radiography. The hookwire films from a freehand localization show the tip of the hookwire in microcalcifications on the craniocaudal (A) and mediolateral (B) views. C, The first specimen shows the hookwire but no calcifications. These findings were reported to the surgeon in the operating room. D, Calcifications are seen in the second specimen.

Tissue excised at ultrasound-guided preoperative localizations also undergoes specimen radiography, even if the finding cannot be seen on mammogram. The specimen radiograph may or may not show the ultrasound-localized finding, but will show if the entire hookwire or its tip, as well as any metallic markers, was excised. If the specimen radiograph does not show the ultrasound-localized finding, the radiologist can perform specimen ultrasound to see if the tissue contains the mass (Figs. 6-5 and 6-6).

Figure 6-5 Ultrasound-guided preoperative needle localization with specimen radiography. In an 18-year-old woman, ultrasound-guided core biopsy of an oval mass in the 6-o’clock position showed pathology suggestive of fibroadenoma versus phyllodes tumor. A marker was placed in the mass. The surgeon requested ultrasound-guided preoperative needle localization. A, The ultrasound shows the bright speckle inside the mass (arrow), representing the marker placed at the time of the core biopsy. This patient then underwent ultrasound-guided preoperative needle localization for excisional biopsy. B, Ultrasound shows the needle within the mass just before wire placement for ultrasound-guided preoperative needle localization. C, Ultrasound shows the wire tip (arrow) in the mass after wire placement through the needle. D, Mammogram after ultrasound-guided needle localization shows the hookwire near the marker in the mass, which is obscured by surrounding dense breast tissue. E, After excisional biopsy, the specimen radiograph shows inclusion of the hookwire, dense tissue, and the marker. Just as on the mammogram, the mass is invisible. F, Ultrasound of the breast specimen shows inclusion of the mass previously seen within the patient. The surgeon was called in the operating room to confirm that he had removed the mass, marker, hookwire, and hookwire tip. Pathology showed fibroadenoma.

Figure 6-6 Ultrasound-guided bracket needle localization. A, Positron emission tomography/computed tomography (PET/CT) shows a mass in the right breast on the CT scan (arrow). B, The mass demontrates increased uptake of fluorodeoxyglucose on the PET scan. C, Ultrasound shows a palpable lobulated, hypoechoic, suspicious mass in the 12-o’clock position on the right breast in transverse plane, corresponding to the mass seen on PET/CT. D, The mass is slightly wider in its caudal aspect. Core biopsy showed cancer. Because the mass was difficult to see against the dense breast tissue on the mammogram, the surgeon requested ultrasound bracket localization. E, Ultrasound bracket localization shows the needle at the medial aspect of the mass (arrow). F, A second wire can be seen in the lateral aspect of the mass (arrow). G, Lateral-medial mammogram after localization shows the two wires at either end of the mass (the mass is difficult to see against the dense tissue). Use of the open aperture of the alphanumeric plate avoids pushing the wires further into the breast. Annotations show clusters of three and four BBs marking the skin entry sites. Single and double BBs show the medial and lateral aspects of the mass, marked by an X written on the skin to help the surgeon find the mass in the operating room. H, Annotated magnified craniocandal view shows the wires next to the mass. Annotations show clusters of three and four BBs marking the skin entry sites. Single and double BBs show the medial and lateral aspects of the mass, marked by an X written on the skin to help the surgeon find the mass in the operating room. I, A specimen radiograph shows inclusion of the mass and the two hookwires. Note that one of the wires no longer inside the specimen was placed within the container to show that it and its tip were removed. J, The same specimen photographed at lighter contrast shows the letters and numbers on the container. The mass is located at coordinates F.0/4.0. K, An ultrasound of the breast specimen shows inclusion of the entire mass scanned at coordinates F.0/4.0, showing that the entire mass and its margins were removed.

Pathology Correlation

Later, the radiologist reviews the pathology report to see if the pathology reflects what the radiologist expected, based on the lesion’s imaging characteristics. Radiologic–pathologic correlation ensures that the targeted lesion analyzed at pathologic evaluation is concordant with the imaging finding and, specifically, that the pathology report describes a histologic finding that is known to correlate with the imaging findings. For example, if the targeted lesion shows fine pleomorphic calcifications, a diagnosis of malignancy, high-risk lesion, or benign lesion would all be concordant if the targeted calcifications were definitely seen in the specimen radiograph and preferably also on the pathology slides (Fig. 6-7). If the pathology report showed an uncalcified fibroadenoma when the targeted radiographic finding was fine pleomorphic calcifications, the pathologic–radiologic correlation would be discordant, and the case would warrant additional investigation.

Figure 6-7 A, Magnification mammogram shows invasive ductal cancer (IDC) and ductal carcinoma in situ (DCIS) as a mass and calcifications previously sampled by stereotactic biopsy. The magnified craniocaudal mammogram shows a spiculated mass, residual calcifications, air, and a metallic marker. This area was localized for surgical excisional biopsy. B, After preoperative localization and excisional biopsy, magnified, cropped specimen radiograph shows the hookwire, hookwire tip, marker, the mass, and calcifications. The uncropped specimen radiograph (not shown) showed that the entire mass and calcifications were removed. Because IDC and DCIS had been shown by stereotactic core biopsy, the radiologist expects IDC, DCIS, and calcifications in the pathology report. Pathology showed IDC, DCIS, calcifications, and postbiopsy change, which was concordant with imaging.

Pathologic–radiologic correlation of targeted calcifications is a special subset of breast biopsy correlation. Calcifications from targeted calcifications must be seen on the surgical specimen radiograph for the biopsy to be concordant. Calcifications seen just on histologic slides and not on the specimen radiograph do not represent the calcified lesion being targeted and are not concordant. Calcifications seen on the specimen radiograph are usually seen on pathology slides, but the pathologist may not see them for several reasons.

First, the calcifications may be calcium oxalate and are seen on the slides. Unlike calcium phosphate calcifications, which are easily seen on hematoxylin and eosin (H&E) staining, calcium oxalate is not visualized with H&E staining and requires a special polarized light to show the calcifications.

Second, the calcifications may be in the paraffin blocks. During specimen processing, thin breast tissue samples are embedded in paraffin blocks, which are then sliced and placed on slides for staining. Each block is several millimeters thick, but each slide contains only micromillimeters of paraffin and tissue. The calcifications may still be in the block and may never have been placed on a slide for review. A radiograph of the blocks may show the calcifications, and re-sectioning of that particular block will show the calcifications (Fig. 6-8).

Figure 6-8 Tissue specimen radiography in pathology department. A, Radiograph of six tissue specimens sectioned from an excisional breast biopsy performed for calcifications. Calcifications are found in all six specimens. B, Magnified view of two tissue specimens containing calcifications (arrows). C, Pathology technologists place the tissue pieces in paraffin in a plastic tissue cassette. This paraffin block radiograph shows the calcifications (arrows) from the two tissue specimens shown in part B. Pathology showed fibrocystic change and calcifications. If the slides from this cassette did not show calcifications, the pathologists would have taken additional samples from this cassette.

(Images courtesy of Dr. Gerald Berry, Stanford University, Palo Alto, CA.)

Third, other calcifications may be removed from the specimen if the microtome cutting device that slices the tissue/paraffin block for slides pushes large calcifications out of the specimen at the time of sectioning.

If the targeted calcifications seemed to be present in the specimen radiograph but no calcifications are found in the pathology slides or in the paraffin blocks, a repeat mammogram can determine whether the calcifications are still in the breast and were not removed at surgery. Rarely, the calcifications seen in the specimen radiograph can be incidental calcifications and not the ones that were targeted.

Percutaneous Needle Biopsy of Cysts, Solid Masses, or Calcifications

Breast lesions can be classified as cysts, solid masslike lesions (which include true masses, asymmetries, and areas of architectural distortion), and calcifications. Needle types and cyst aspirations are discussed here, followed by needle biopsies guided by palpation, ultrasound, and stereotactic techniques. Needle biopsies guided by MRI are discussed in Chapter 7. This section then discusses core specimen radiography, marker placement, carbon marking, patient safety and comfort after biopsy, complete lesion removal, calcification and epithelial displacement, pathology correlation, high-risk lesions, follow-up of benign lesions, complications, differences between core and vacuum needle biopsies, and patient follow-up, audits, and noncompliance.

Needle Types

The types of biopsy needles used for specific breast lesions and guidance methods vary around the world. A trend toward progressively larger needles and more tissue samples per biopsy site has been noted, especially in the United States. Three main types of needles are used for percutaneous biopsies (Table 6-1). Fine-needle aspiration (FNA) needles, usually 25- to 20-gauge, are used for cyst aspirations and for solid breast masses. The aspirated material requires interpretation by expert cytopathologists. FNA is usually done with ultrasound or palpation guidance with at least four needle passes. FNA is less commonly done in the United States compared to Europe and Asia.

Table 6-1 Needles Used for Percutaneous Breast Biopsies

Needle Type	Usual Gauge	Biopsy Use
Fine-needle aspiration	25- to 20-gauge	Cyst aspiration. Solid mass highly likely to be either benign or malignant
Automated large-core	18- to 14-gauge	Ultrasound-guided biopsy. Uncommon for stereotactic biopsy
Directional vacuum-assisted	14- to 7-gauge	Stereotactic biopsy. Uncommon but growing use for ultrasound-guided biopsy

Automated large-core (core) needles in 18- to 14-gauge (Fig. 6-9A and B) commonly are used to biopsy masses with ultrasound or palpation guidance. In some facilities, especially outside the United States, core needles are used with stereotactic guidance to biopsy masses or calcifications. An automated large-core biopsy needle obtains a single specimen with each pass of the needle, and 2 to 12 specimens are obtained by firing the needle multiple times. Pathologists who are comfortable interpreting surgically excised breast biopsy tissue can interpret the histologic material obtained.

Figure 6-9 Needle types and coaxial guide for core needle biopsy. A, Schematic of core biopsy needle parts showing the needle, coaxial sheath, and inner stylet. B, Schematic of how to use a multifire core biopsy needle for breast biopsies. The outer cutting cannula shoots over the trough and cuts the mass. The entire needle is removed each time. C, Schematic of a vacuum-assisted probe for needle core biopsy. The outer cutting cannula shoots over the trough and cuts the mass. The vacuum transports the specimen to the needle end for removal. There may be one or multiple insertions, depending on the vendor.

Directional vacuum-assisted (vacuum) needles (see Fig. 6-9C) are available in 7- to 14-gauge and are used for stereotactic, ultrasound-guided, and MRI-guided biopsies. Depending on the manufacturer, vacuum biopsy can be done with just one needle pass, and multiple specimens are obtained by rotating the collection aperture of the needle to obtain between 6 and 18 specimens. Other directional vacuum-assisted needles obtain single vacuum specimens with each pass, requiring multiple insertions. In some facilities, vacuum biopsies are used to excise benign lesions such as fibroadenomas to avoid the need for surgical excision or imaging follow-up, once the fibroadenoma has been diagnosed by core needle biopsy and adequate sampling.

Both single-insertion and multi-insertion needles can be used with or without a coaxial guide (Fig. 6-10A). The coaxial guides are usually used with ultrasound or MRI guidance. The purpose of the coaxial guide is to provide a path to the target that the radiologist can use again and again without retraumatizing the breast tissue. The coaxial device consists of an inner sharp stylet and an outer sheath. The coaxial device is placed through the tissue so that the stylet tip/sheath edge is at or in the lesion. Then the radiologist removes the stylet, leaving a sheath that provides a “tunnel” through the breast tissue directly to the lesion. The radiologist then places the biopsy needle through the sheath into the lesion and takes samples. The radiologist can repeatedly place the biopsy needle through the sheath without having to disturb the surrounding breast tissue. Coaxial biopsies can be done with the sheath near the mass or through the mass (see Fig. 6-10B).

Figure 6-10 A, Schematic of how to use a coaxial sheath next to a mass for ultrasound-guided core biopsies. The radiologist places a coaxial containing a sharp, inner stylet through the breast tissue next to a mass. The radiologist removes the stylet, places a core biopsy needle through the coaxial sheath, fires the needle through the mass, and withdraws the needle. The coaxial sheath is left adjacent to the mass, providing a tunnel through the breast tissue. The radiologist removes the specimen from the needle and can replace the needle through the coaxial sheath for the next core. B, Schematic of how to use a coaxial sheath inside a mass for ultrasound-guided core biopsies. The radiologist places a coaxial containing a sharp, inner stylet into a mass. The radiologist removes the stylet, places an open core biopsy needle through the coaxial sheath, withdraws the coaxial to expose the biopsy trough inside the mass, and fires the needle to take the sample. Before withdrawing the biopsy needle, the radiologist threads the coaxial sheath over the fired needle and leaves the sheath inside the mass. The core biopsy needle can now be replaced into the sheath to take the next sample.

Cyst Aspiration

Masses on mammograms often prompt requests for breast ultrasound and cyst aspiration. To do a cyst aspiration the radiologist advances a fine needle into the cyst by palpation or image guidance. If the cyst is tense, fluid wells up into the needle hub. To aspirate the cyst, the radiologist attaches a syringe to the needle and draws fluid into the syringe until no more fluid can be obtained. Cyst aspiration can be done by ultrasound (Fig. 6-11) or, less commonly, by x-ray guidance using a fenestrated compression plate and mammography. If cyst aspiration is done under ultrasound, the radiologist should be able to watch the cyst disappear in real time.

Figure 6-11 Cyst aspiration. A, Ultrasound shows a needle in a cyst near an implant. B, The follow-up ultrasound shows that the cyst is gone.

Aspirated fluid is sent for cytologic evaluation only if an intracystic mass is present or the fluid is bloody. A large series of cyst aspirations by Tabar and colleagues showed that cyst fluid cytology is often falsely negative, even in the presence of an intracystic mass. In these cases, the pneumocystogram was enough to diagnose an intracystic mass and prompt biopsy of the rare intracystic cancer.

Pneumocystograms are mammograms obtained after the radiologist injects air into a cyst cavity. The pneumocystogram shows the air-filled cyst cavity on the mammogram, enabling the radiologist to make sure that a mass prompting biopsy on the mammogram corresponds to the aspirated cyst and to exclude an intracystic mass. Air is thought to be therapeutic in preventing cyst recurrence (Fig. 6-12). To do a pneumocystogram, the radiologist aspirates the cyst first. Once the fluid has been aspirated completely, the radiologist disengages the syringe while carefully holding the needle tip in the decompressed, flattened cyst cavity. The radiologist attaches an air-filled syringe to the needle, injects a small amount of air into the cyst cavity, takes the needle out, and obtains CC and mediolateral mammograms immediately. A normal pneumocystogram should show an air-filled, thin-walled, round or oval cavity without intracystic solid masses or mural nodules.

Figure 6-12 Pneumocystogram. A, A craniocaudal (CC) mammogram shows an oval breast mass in the inner portion of the breast. B, Ultrasound shows a complicated cyst versus a solid oval mass. After cyst aspiration under ultrasound guidance, air was placed in the cyst cavity. CC (C) and lateral (D) pneumocystogram mammograms show air (arrows) replacing fluid in the mass, which confirms that the finding on the mammogram represents a cyst that was aspirated.

Although radiologists can usually tell if a cyst on ultrasound corresponds to a specific mammographic mass, this correlation can be tricky. When the correlation is unclear and the radiologist has chosen not to do a pneumocystogram, the radiologist orders a postaspiration mammogram to see if the “cyst” disappears. The mass should be gone on the postaspiration mammogram if the aspirated cyst is the mammographic mass. If the mass still shows on the postaspiration mammogram, the mammographic finding is separate from the cyst and needs further investigation (Fig. 6-13).

Figure 6-13 Correlating mammography and ultrasound after cyst aspiration. Right mediolateral oblique (MLO) (A) and craniocaudal (CC) (B) views show a possible mass on screening mammography (circles). C, Ultrasound shows a probable multiseptated, complicated cyst in the expected location of the mammographic mass. D, Fine-needle aspiration under ultrasound shows the needle in the mass. E, Cyst fluid was aspirated and the mass disappeared. Postaspiration MLO (F) and CC (G) views show that the mammographic mass disappeared, indicating that the ultrasound and mammographic findings represented the same simple cyst.

Ultrasound Guidance

When compared with stereotactic biopsy, ultrasound-guided biopsy has the advantage of using readily available equipment and is fast and cost-effective. The first step in ultrasound-guided biopsy is to find the questioned lesion for biopsy. This commonly occurs when a mass on the mammogram prompts an ultrasound to further characterize the mass and localize it for biopsy. When correlating the mammogram to the ultrasound, the mass can be far away from the chest wall on the mammogram and lie next to the pectoralis muscle on the ultrasound. This occurs because the breast tissue is compressed far away from the chest wall when the patient stands up for the mammogram. On ultrasound, the breast falls dependently onto the chest wall when the patient lies down (Fig. 6-14A).

Figure 6-14 Schematics of how masses appearing to be far away from the chest wall on mammography may be found near the chest wall on ultrasound and how to keep the needle tip away from the chest wall on ultrasound-guided core biopsy A, Schematic mammograms show a mass in the upper inner quadrant that appears to be far from the chest wall. However, mammograms are obtained with compression; when the patient lies supine, the mass falls dependently against the chest wall. On ultrasound, the mass may be closer to the chest wall than expected from the mammogram. B, With superficial lesions, the needle tip and throw are usually far away from the chest wall. C, With deeper lesions, the needle angle is steeper, and the radiologist judges whether the needle “throw” will penetrate the lung. D, When the patient is flat and the lesion is even deeper, the needle trajectory can point toward the chest wall. E, To change the needle trajectory, the patient can be angled so that her chest wall parallels the needle track/throw. F, Injecting anesthetic underneath the lesion can lift it away from the chest wall for biopsy. G, Inserting the needle tip into the lesion and redirecting the throw of the needle avoids placing the needle tip into the chest wall.

(B to G, Courtesy of Dr. Sunita Pal, Stanford Radiology, Stanford, CA.)

When planning ultrasound-guided needle biopsies, it is important to keep the needle tip away from the chest wall to prevent pneumothorax. Unlike upright preoperative x-ray–guided needle localization or prone stereotactic localization, the ultrasound-guided biopsy is done supine and the needle is not necessarily parallel to the chest wall. Further complicating matters, some core biopsy needles “throw” the cutting trough 2.5 cm further into the tissue beyond the needle tip. Thus, planning a safe ultrasound-guided needle biopsy trajectory must take into account both the needle tip and the needle “throw” trajectory. To plan a safe procedure, the radiologist rolls the patient on the table so that the needle trajectory is as parallel to the chest wall as possible and not at a steep angle aiming toward the lungs. Patient positioning can take some time, but it is worth the few minutes to position the patient accurately to avoid an untoward complication. Another way to keep the needle away from the chest wall is to inject anesthetic underneath the targeted mass to lift it away from the pectoralis muscle. Alternatively, in some cases, the radiologist can stick the biopsy needle tip into the mass and lift it into a safer trajectory before firing the needle (see Fig. 6-14B to G).

For ultrasound-guided FNA, the radiologist introduces a needle in the plane of the transducer axis to show the entire shaft of the needle, its tip, and the lesion. Once the needle is within the lesion, the radiologist aspirates the mass with a vigorous to-and-fro movement to obtain material for cytologic evaluation and then withdraws the needle. At least four passes should be performed; optimally, the material should be analyzed immediately to ensure that adequate cellular material has been obtained for diagnosis. After aspiration, direct pressure is applied to the site (Fig. 6-15).

Figure 6-15 Fine-needle aspiration of axillary lymphadenopathy in a patient with invasive ductal cancer. A, Initial ultrasound shows a large invasive ductal cancer in the upper left breast undergoing ultrasound-guided core biopsy. B, Ultrasound of the left axilla in this patient shows a lymph node with an enlarged, thickened cortex, suspicious for metastatic disease. C, Fine-needle aspiration under ultrasound guidance shows the needle tip in the lymph node cortex (arrow). Cytology showed lymph node metastases. D, In another patient, the right axillary lymph node has an irregular, thickened cortex and a compressed fatty hilum. E,

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• Breast Cancer Treatment-Related Imaging and the Postoperative Breast
• Breast Ultrasound
• Magnetic Resonance Imaging of Breast Cancer and MRI-Guided Breast Biopsy
• Mammographic and Ultrasound Analysis of Breast Masses
• Mammogram Interpretation
• Mammographic Analysis of Breast Calcifications
• Clinical Breast Problems and Unusual Breast Conditions
• Breast Implants and the Reconstructed Breast

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