Step-by-step of ultrasound-guided core-needle biopsy of the breast: review and technique

Ultrasound-guided core-needle biopsy has high sensitivity in the diagnosis of breast cancer. The present study is aimed at detailing the main steps of such procedure, including indications, advantages, limitations, follow-up and description of the technique, besides presenting a checklist including the critical steps required for an appropriate practice of the technique. In the recent years, an increasing number of patients have required breast biopsy, indicating the necessity of a proportional increase in the number of skilled professionals to carry out the procedures and histological diagnoses. A multidisciplinary approach involving the tripod clinical practice-radiology-pathology is responsible for the highest rate of accuracy of the technique and must always be adopted.

Ultrasound-guided core-needle biopsy; Breast

Authorship

Rafael Dahmer Rocha

MD, Resident in Radiology and Diagnostic Imaging, Hospital Federal dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.Hospital Federal dos Servidores do Estado do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilMD, Resident in Radiology and Diagnostic Imaging, Hospital Federal dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Renata Reis Pinto

MD, Mastologist, Hospital do Instituto Nacional de Câncer (INCA), Rio de Janeiro, RJ, Brazil.Hospital do Instituto Nacional de CâncerBrazilRio de Janeiro, RJ, BrazilMD, Mastologist, Hospital do Instituto Nacional de Câncer (INCA), Rio de Janeiro, RJ, Brazil.

Diogo Paes Barreto Aquino Tavares

Head of Interventional Radiology Department, Hospital Federal dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.Hospital Federal dos Servidores do Estado do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilHead of Interventional Radiology Department, Hospital Federal dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Cláudia Sofia Aires Gonçalves

MD, Radiologist, Hospital Federal dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.Hospital Federal dos Servidores do Estado do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilMD, Radiologist, Hospital Federal dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Mailing Address: Dr. Rafael Dahmer Rocha. Avenida XV de Novembro, 70, ap. 801, Centro. Joaçaba, SC, Brazil, 89600-000. E-mail: rafaeldrocha@gmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Figures | Tables

Figures (5)
Tables (4)

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Figure 1.
Arrangement of materials required for the performance of core biopsy of breast. Fenestrated surgical drape, scalpel blade, 18-gauge to 22-gauge needles, 5-10 ml syringe, vial with 5-10 ml of 10% formalin, sterile gloves and gauze pads, automated core biopsy device and 14-gauge core biopsy needle.

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Figure 2.
Main steps of ultrasonography-guided core biopsy of breast. A and E: Identification of the suspicious lesion (asterisk). B and F: Infiltration of the anesthetic though the pathway up to the lesion. The anesthetic needle is visualized as a fine hyperechogenic line (wide arrows). C: 2-3 mm incision on the numbed area. D and G: Through the incision, the same pathway utilized for anesthesia is utilized for insertion of the core needle (thin arrows) up to the lesion border. H: Once the CB devise is triggered, one must check whether the needle penetrated the lesion (asterisks). It is possible to observe the segment of the needle which advanced over the nodule (space between arrows).

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Figure 3.
Commonly utilized approaches at US-guided core biopsy of breast. A: Needle parallel to the chest wall, perpendicular to the transducer. Better sonographic visualization of the needle and lower risk for pneumothorax. B: Needle angulated in relation to the chest wall. The transducer is guided in an attempt to maintain a perpendicular angle. Useful in very deep or superficial central lesions. C: The inferior movement of the CB device may help to move the lesion away as much as possible from the chest wall.

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Figure 4.
Post-triggering air artifact. A: Needle path (wide arrows) within the nodule (asterisk) during biopsy. B: After biopsy, a small amount of gas can be observed, represented by a hyperechogenic line (thin arrows). Such artifact may be useful in the determination of lesion locations yet to be biopsied.

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Figure 5.
Appropriate specimens of breast core biopsy: predominantly white, integral and sinks in the solution.

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Table 1
Indications for core breast biopsy according to the BI-RADS category of images (mammography, ultrasonography and magnetic resonance imaging).

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Table 2
Advantages and limitations of US-guided core biopsy of breast.

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Table 3
Checklist for US-guided core biopsy of breast.

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Table 4
Radiological-pathological correlation of core biopsy of breast.

Figure 1. Arrangement of materials required for the performance of core biopsy of breast. Fenestrated surgical drape, scalpel blade, 18-gauge to 22-gauge needles, 5-10 ml syringe, vial with 5-10 ml of 10% formalin, sterile gloves and gauze pads, automated core biopsy device and 14-gauge core biopsy needle.

Figure 2. Main steps of ultrasonography-guided core biopsy of breast. A and E: Identification of the suspicious lesion (asterisk). B and F: Infiltration of the anesthetic though the pathway up to the lesion. The anesthetic needle is visualized as a fine hyperechogenic line (wide arrows). C: 2-3 mm incision on the numbed area. D and G: Through the incision, the same pathway utilized for anesthesia is utilized for insertion of the core needle (thin arrows) up to the lesion border. H: Once the CB devise is triggered, one must check whether the needle penetrated the lesion (asterisks). It is possible to observe the segment of the needle which advanced over the nodule (space between arrows).

Figure 3. Commonly utilized approaches at US-guided core biopsy of breast. A: Needle parallel to the chest wall, perpendicular to the transducer. Better sonographic visualization of the needle and lower risk for pneumothorax. B: Needle angulated in relation to the chest wall. The transducer is guided in an attempt to maintain a perpendicular angle. Useful in very deep or superficial central lesions. C: The inferior movement of the CB device may help to move the lesion away as much as possible from the chest wall.

Figure 4. Post-triggering air artifact. A: Needle path (wide arrows) within the nodule (asterisk) during biopsy. B: After biopsy, a small amount of gas can be observed, represented by a hyperechogenic line (thin arrows). Such artifact may be useful in the determination of lesion locations yet to be biopsied.

Figure 5. Appropriate specimens of breast core biopsy: predominantly white, integral and sinks in the solution.

Table 1 Indications for core breast biopsy according to the BI-RADS category of images (mammography, ultrasonography and magnetic resonance imaging).

BI-RADS 5

BI-RADS 4

BI-RADS 3

- Patient's and/or assisting physician will

- Psychological factors

- Short-interval follow-up difficulties

- Patients with multiple risk factors for breast cancer

- Need for diagnostic anticipation

Table 2 Advantages and limitations of US-guided core biopsy of breast.

Advantages

- Evaluation of tumor grade and hormone receptors^* * Advantages over fine needle aspiration biopsy. (¹⁹19. Harvey JA, Moran RE. US-guided core needle biopsy of the breast: technique and pitfalls. Radiographics. 1998;18:867-77. ³⁴34. Non-operative Diagnosis Subgroup of the National Coordination Group for Breast Screening Pathology. Guidelines for non-operative diagnostic procedures and reporting in breast cancer screening. NHSBSP Publication No. 50. Sheffield: NHS Cancer Screening Programmes; 2001.

35. Wallis M, Tarvidon A, Helbich T, et al. Guidelines from the European Society of Breast Imaging for diagnostic interventional breast procedures. Eur Radiol. 2007;17:581-8.

36. Verkooijen HM, Peeters PH, Buskens E, et al. Diagnostic accuracy of large-core needle biopsy for nonpalpable breast disease: a meta-analysis. Br J Cancer. 2000;82:1017-21.-³⁷37. Helbich TH, Matzek W, Fuchsjäger MH. Stereotactic and ultrasound-guided breast biopsy. Eur Radiol. 2004;14:383-93.)

- Real time image

- Accessibility to all areas of the breast

- Absence of ionizing radiation

- Low incidence of complications and discomfort for the patient(¹²12. Parker SH, Jobe WE, Dennis MA, et al. US-guided automated large-core breast biopsy. Radiology. 1993;187:507-11. ¹³13. Liberman L, Feng TL, Dershaw DD, et al. US-guided core breast biopsy: use and cost-effectiveness. Radiology. 1998;208:717-23. ¹⁷17. Dillon MF, Hill AD, Quinn CM, et al. The accuracy of ultrasound, stereotactic, and clinical core biopsies in the diagnosis of breast cancer, with an analysis of false-negative cases. Ann Surg. 2005;242:701-7. ²⁰20. Philpotts LE, Hooley RJ, Lee CH. Comparison of automated versus vacuum-assisted biopsy methods for sonographically guided core biopsy of the breast. AJR Am J Roentgenol. 2003;180:347-51. ²¹21. Parker SH, Burbank F, Jackman RJ, et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology. 1994;193:359-64. ³⁴34. Non-operative Diagnosis Subgroup of the National Coordination Group for Breast Screening Pathology. Guidelines for non-operative diagnostic procedures and reporting in breast cancer screening. NHSBSP Publication No. 50. Sheffield: NHS Cancer Screening Programmes; 2001.)

- Procedure swiftness (about 20 minutes)(¹²12. Parker SH, Jobe WE, Dennis MA, et al. US-guided automated large-core breast biopsy. Radiology. 1993;187:507-11. ¹³13. Liberman L, Feng TL, Dershaw DD, et al. US-guided core breast biopsy: use and cost-effectiveness. Radiology. 1998;208:717-23.)

- Wide availability of the utilized equipment

- One-half to one-fourth of the cost of surgical biopsy(¹³13. Liberman L, Feng TL, Dershaw DD, et al. US-guided core breast biopsy: use and cost-effectiveness. Radiology. 1998;208:717-23. ²¹21. Parker SH, Burbank F, Jackman RJ, et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology. 1994;193:359-64. ³⁸38. Burkhardt JH, Sunshine JH. Core-needle and surgical breast biopsy: comparison of three methods of assessing cost. Radiology. 1999;212:181-8.)

Technical limitations

- Difficulty in visualizing the finding

- Cystic lesions

- Nodules < 5 mm

- Need for a new biopsy in selected cases

- Breast implants

Limitations related to the patient

- Cooperation incapacity

- Hemorrhagic diathesis

- Use of oral anticoagulant medications

- Allergy to the anesthetic agent

^*
Advantages over fine needle aspiration biopsy.

Table 3 Checklist for US-guided core biopsy of breast.

1. Review previous imaging studies and perform a well documented targeted ultrasonography scan.

2. Evaluate whether the biopsy is appropriately indicated and its limitations (Tables 1 and 2).

3. Obtain the term of free and informed consent from the patient after having explained its entire contents.

4. Define the pathway to approach the lesion, as well as which of the physician's hands will be used for each function.

5. Carry out the antisepsis of the transducer and prepare the materials on a portable table.

6. Don the sterile gloves and couple the core biopsy needle (14G) to the device. Perform a triggering test, checking out the needle travel, as well as the triggering sound from the device.

7. Aspirate the anesthetic agent (1-2% lidocaine without vasoconstrictor).

8. Positioning the patient (usually in dorsal or anterior oblique decubitus).

9. Perform the antisepsis over a wide area around the lesion, over which a sterile fenestrated drape should be placed. The antiseptic or sterile gel will serve as an ultrasound conductive agent.

10. Sonographically identify the lesion. The palm of the hand holding the transducer and the fourth and fifth fingers exert some pressure on the breast to avoid its motion.

11. Remember the access and entry point defined on item 4. Under US guidance, inject the anesthetic agent through the entire pathway up to the lesion.

12. Make a 2-3 mm incision on the skin over needle entry point.

13. Insert the biopsy needle through the incision, attempting to follow the same pathway of the anesthetic needle towards the lesion border. At this point, the needle is to be directed to a position parallel to the nodule.

14. Tell the patient that a sample is about to be obtained, and trigger the device action.

15. Cross sectionally and longitudinally slide the transducer aiming at verifying whether the needle penetrated the nodule and that no injury occurred to the chest wall.

16. Retrieve the sample from the needle with the scalpel blade or sterile needle, placing it in the vial with formaldehyde, briefly evaluating its characteristics.

17. Repeat steps 13 to 16 until a minimum of five good samples are obtained, preferably from different areas of the lesion (center, 3, 6, 9, and 12 o'clock positions). In cases of microcalcifications, at least ten samples should be collected and submitted to radiography, identifying and separating those without calcifications from the ones with calcium.

18. Compress the lesion and incision areas for at least five minutes and apply local ice.

19. Perform asepsis and apply compressive dressings which should be left in place for 24-48 hours.

20. Instruct the patient to avoid intense physical exertion and prescribe pain-relievers and non-steroid anti-inflammatory medication, as necessary.

21. Clarify doubts and schedule return as soon as the histopathological results are available. The approach should be adopted according to Table 4.

^*
Note: The presence of an assistant is valuable during the procedure. Such an assistant can perform the functions described on items 5, 8, 9, 16,18 and 19. This will make the procedure swifter and the physician will be able to exert compression on the breast after triggering the CB device, thus decreasing the risk for development of hematoma.

Table 4 Radiological-pathological correlation of core biopsy of breast.

Classification	Radiological result	Histological result	Recommended approach
Concordant benign results	BI-RADS 3 or 4	Benign lesions	Six-month imaging follow-up
Discordant benign results	BI-RADS 5	Benign lesions	Surgical biopsy
Risk lesions, precursor lesions, or lesion at risk for underestimation	Independent	Carcinoma in situ, radial scar, atypical epithelial proliferation, lobular neoplasias, papilliferous lesions, fibroepithelial lesion (with possibility of phyllodes tumor)	Surgical biopsy
Malignant	Independent	Infiltrative carcinoma	Contact assisting physician

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