Chapter 43 Image-Guided Breast Biopsy
INTRODUCTION
Increased utilization of mammography screening is believed to have resulted in a relative increase in breast abnormalities of sufficient risk to warrant a biopsy. It is estimated that approximately 1.5 million breast biopsies are performed each year in the United States. Many of these biopsies are for nonpalpable lesions and, therefore, require some type of image guidance. A significant number of these biopsies will be performed for benign disease because the average positive predictive value for mammography is only 20% (range 15%–35%).1–4 If traditional methods for histologic confirmation were utilized, all women with nonpalpable breast lesions would proceed to the operating room after a wire localization procedure was performed in the radiology suite. Percutaneous image-guided breast biopsy has become an effective minimally invasive alternative to open surgical breast biopsy for the diagnosis of both palpable and nonpalpable image-detected abnormalities.5–7 Although the risk of bleeding and infection may be comparable with those of open surgical breast biopsy, some potential difficulties are unique to image-guided breast biopsy.8
With the early introduction by the Karalinski Institute in 1989 of stereotactic-guided fine-needle aspiration cytology of nonpalpable breast abnormalities,9 image-guided percutaneous breast biopsy has been shown to provide a secondary level of screening in a less-invasive, cost-effective manner to obtain a histologic diagnosis without sacrificing accuracy.5–7,10 The evolution of the biopsy tools used with image guidance (stereotaxic, ultrasound, and recently, magnetic resonance imaging [MRI]) has added to the accuracy of minimally invasive image-guided breast biopsy,11,12 keeping a greater portion of women with probably benign disease out of the operating room for a diagnostic procedure. However, advancement in technology has also added to the potential procedural risks.13
INDICATIONS
Almost any palpable or nonpalpable, indeterminate breast abnormality, which is visualized with imaging modalities (ultrasound, mammography, MRI), can be evaluated with image-guided breast biopsy. The lesions will fall into the following categories established by the American College of Radiology (ACR) lexicon14:
Stereotactic Breast Biopsy
Stereotaxis mammography determines the position of a nonpalpable breast abnormality by utilizing computerized triangulation of the targeted lesion visualized with two stereo images, separated by a 30° arc.5,15 The equipment for performing a stereotactic breast biopsy is either a dedicated prone table or an add-on unit, which utilizes a targeting and biopsy platform attached to a standard upright mammogram system.15,16 Add-on stereotactic breast biopsy units have been traditionally less popular because the upright patient position and patient visualization of the procedure have the potential for producing increased syncopal episodes.5,17 The advantages of the prone position include gravity to assist the technologist with posterior lesions and a greatly enhanced workspace beneath the table.18 Both are important for positioning and access, which limit many of the potential difficulties in achieving a successful biopsy.
OPERATIVE STEPS
OPERATIVE PROCEDURE
Evaluating the Mammogram and the Patient and Choosing the Approach to the Breast
Choosing an Inappropriate Mammogram Lesion Type for Biopsy
• Consequence
• Prevention
Failure to Recognize Patient Characteristics that Will Result in an Unsuccessful Stereotactic Breast Biopsy
• Consequence
• Prevention
Not Choosing the Ideal Approach to the Breast
• Consequence
• Repair/Prevention
Failure to Recognize the Position of the Lesion in the Breast
• Consequence
• Repair
Failure to Visualize the Lesion on Both Stereo Images
• Consequence
• Repair
Patient Positioning
Failure to Image a Lesion that is Deep against the Pectoral Muscle
• Consequence
Obtain Scout and Stereo Digital Images
Not Correctly Positioning the Breast Lesion within the Compression Window
• Consequence
Failure to Recognize the Depth of a Lesion in the Breast
• Consequence
• Repair
• Prevention
Targeting the Lesion
A Negative Stroke Margin
• Consequence
• Repair
• Prevention
Prepare the Breast: Skin Preparation, Local Anesthesia, and Skin Incision
Using Local Anesthetic with Epinephrine in the Skin
• Consequence
Injecting Too Much Local Anesthetic
• Consequence
• Repair
• Prevention
Insertion of the Biopsy Device
Failure to Recognize Specific Insertion Depths for Different Devices
• Consequence
• Prevention
Inability to Avoid a Negative Stroke Margin
• Consequence
• Repair
Assess Appropriate Alignment between the Lesion and the Biopsy Device on Prebiopsy and/or Postbiopsy Alignment Stereo Digital Images
Failure to Recognize Targeting Errors
• Consequence
• Repair
• Prevention
Adequately Sample the Lesion for Diagnosis and/or Potential Therapeutic Removal
Failure to Choose the Correct Biopsy Device
• Consequence
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
Stay updated, free articles. Join our Telegram channel
![](https://clinicalpub.com/wp-content/uploads/2023/09/256.png)
Full access? Get Clinical Tree
![](https://videdental.com/wp-content/uploads/2023/09/appstore.png)
![](https://videdental.com/wp-content/uploads/2023/09/google-play.png)
![](https://clinicalpub.com/wp-content/uploads/2023/09/banner1.png)