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(BQ) Part 1 book Diagnostic breast imaging - Mammography, sonography, magnetic resonance imaging and interventional procedures presents the following contents: Patient history and communication with the patient, clinical findings, mammography, magnetic resonance imaging, percutaneous biopsy,...
I Diagnostic Breast Imaging 2nd edition II III Diagnostic Breast Imaging Mammography, Sonography, Magnetic Resonance Imaging, and Interventional Procedures Second edition, enlarged and revised Sylvia H Heywang-Köbrunner, M.D Associate Professor and Substitute Director Department of Diagnostic Radiology Martin Luther University Halle-Wittenberg Halle, Germany D David Dershaw, M.D Director, Breast Imaging Section Department of Radiology Memorial Sloan-Kettering Cancer Center New York, NY USA Ingrid Schreer, M.D Assistant Professor Breast Center University Hospital Kiel, Germany In collaboration with Professor Roland Bässler, M.D 843 illustrations Thieme Stuttgart · New York 2001 IV Library of Congress Cataloging-in-Publication Data Heywang-Köbrunner, Sylvia H., 1956[Bildgebende mammadiagnostik English] Diagnostic breast imaging : mammography, sonography, magnetic resonance imaging, and interventional procedures / Sylvia Heywang-Köbrunner, Ingrid Schreer, D David Dershaw ; in collaboration with Roland Bässler ; translated by Peter F Winter.— 2nd ed., enlarged and rev p ; cm Includes bibliographical references and index ISBN 3131028920—ISBN 1-58890-033-9 Breast—Imaging Breast—Diseases—Diagnosis I Schreer, Ingrid II Dershaw, D David III Title [DNLM: Breast—pathology Breast Diseases— diagnosis Biopsy—methods Magnetic Resonance Imaging Mammography Ultrasonography, Mammary WP 815 H622b 2000a] RG493.5D52 H49 I3 2000 618.1’90754—dc21 00-048876 Collaborator: Roland Bässler, M.D Professor, Institute of Pathology Municipal Clinics Fulda, Germany 1st German edition 1996 1st English edition 1997 This book is an enlarged and revised new edition of the authorized translation of the German edition, published and copyrighted 1996 by Georg Thieme Verlag, Stuttgart, Germany Title of the German edition: Bildgebende Mammadiagnostik: Untersuchungstechnik, Befundmuster und Differentialdiagnostik in Mammographie, Sonographie und Kernspintomographie Important Note: Medicine is an ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of application stated in the book Every user is requested to examine carefully the manufacturer’s leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed First edition translated by Peter F Winter, M D © 2001 Georg Thieme Verlag Rüdigerstrasse 14, 70469 Stuttgart, Germany Thieme New York, 333 Seventh Avenue, New York, N.Y 10001 USA Typesetting by primustype Robert Hurler GmbH 73274 Notzingen, Germany Printed in Germany by Druckhaus Götz, Ludwigsburg ISBN 3-13-102892-0 (GTV) ISBN 0-58890-033-9 (TNY) Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilm, and electronic data processing and storage V Preface The authors present a second edition of this book, encouraged by the success of the first edition The second edition became necessary due to the technologic progress, increasing clinical data, as well as evolving, and new clinical and imaging strategies During the last years data has continued to accumulate on the value of screening mammography for reduction of breast cancer mortality in the 50−70-year age group Furthermore, increasing proof now exists that similar results can also be achieved by screening women aged 40−49 Simultaneously, other imaging modalities as well as various methods for percutaneous biopsy have been further developed and improved These increasingly supplement mammography in cases of diagnostic difficulties and in the assessment and management of women with breast disease In addition to standard two-view mammography and clinical examination, special mammographic views and sonography are an important part of the imaging workup of these women For selected indications MR imaging increasingly proves to provide valuable additional information Percutaneous biopsy techniques under imaging guidance have become an indispensable tool for minimally invasive diagnosis of imaging detected abnormalities In this second edition, the authors have again attempted to present to the reader a cogent approach to imaging of the breast, updating the information available in the first edition Again, the value of imaging is analyzed for both the symptomatic patient and the asymptomatic woman The latest results of breast cancer screening (including younger age groups and latest discussions concerning the overall value) and the value of other imaging techniques in this clinical context are reviewed New information concerning genetic and other risk factors are included to provide sufficient background for proper application and interpretation of imaging studies in these patients The latest technologic progress in mam- mography, ultrasound, MRI, and percutaneous biopsy techniques has been included, and its present and future impact on diagnostic strategies are considered A critical analysis of new modalities under investigation has been added Based on both technologic progress in mammography, ultrasound, MRI, and percutaneous biopsy and based on evidence from increasing studyproven data, standards and strategies of workup undergo continuous evolution and adaptation The authors have presented algorithms for patient management based on this new material These algorithms take into account the constantly increasing knowledge in this field, and they reflect state-of-the-art technology and clinical knowledge in mid-2000 As in the first edition, the authors have reviewed the clinical, histopathologic, and imaging issues of breast disease together, in order to provide the necessary background for a sensible approach The book is not designed to replace interdisciplinary work Rather, it is hoped it will create an understanding of the value of close interdisciplinary cooperation, which is needed to achieve an optimum diagnosis and treatment for the patient with breast disease For those involved in breast imaging this text presents findings associated with breast diseases and the differential diagnosis for each of these The authors also have suggested algorithms for the workup of a variety of clinical and imaging dilemmas These chapters are designed to assist in the workup of the symptomatic women and the interpretation of abnormal imaging studies This text is also designed to review for nonradiologist physicians the role of breast-imaging technologies in the workup of their patients and the concepts involved in the interpretation of these studies Additonally, the authors also hope that this work will be useful to technologists who wish to add depth to their understanding of the images they create VI Preface Finally it should be pointed out that this work has grown out of an international collaboration Although the philosophy of which technologies are best used in which settings can vary from nation to nation, as well as from office to office, the fear of breast cancer and its impact on individual women affected by this disease and those who share their lives is without borders We have attempted to present a rational approach to the early diagnosis of this disease for women of all nations Acknowledgements The production of this book represents not only the time and effort of the authors whose names appear on the cover, but multiple other individuals We would all like to thank the technologists with whom we work on a daily basis for their tireless efforts and constant compassion in producing the images that appear on these pages We would also like to express our appreciation to Cliff Bergman at Thieme who helped us create the first edition of this text and guided us through the second edition In addition, each of us would like to thank special individuals who have made this project possible Sylvia H Heywang-Köbrunner would like to express her sincere thanks to those colleagues who have accompanied her for many years and who have made high-quality work and research possible by their constant support, enthusiasm, and their care for the patient: Dr Rainer Beck, Dr Thomas Hilbertz, Dr Petra Viehweg, Dr Anke Heinig and numerous other young colleagues and students, who joined us in our efforts and supported our work She is very greatful for the unique cooperation with her clinical partners from gynecology, breast surgery, and pathology: Prof Dr W Permanetter, Prof Dr H Hepp, Prof Dr F.-W Rath, PD Dr J Buchmann, Dr D Lampe, and Prof Dr H Kölbl Deep appreciation goes to Prof Dr R Bässler, who reviewed crucial parts of this book A special note of gratitude is addressed to the technologists at the University of Halle, particularly Ms Klemme and Ms Theuerkorn, for whom quality and patient care have always been the most important goal and who have constantly supported research and teaching at our institution A special note of gratitude must be accorded to Ms A Fulbrecht, who typed major parts of the manuscript Sincere thanks go to Prof Dr Dr J Lissner and Prof Dr R P Spielmann, who supported this work Finally the author would like to express her deep gratitude to Deutsche Krebshilfe (German Cancer Foundation) for continuous support of both education and research associated with numerous projects D David Dershaw would like to acknowledge the constant support, intellectual stimulation, and forbearance of his colleagues in breast imaging at Memorial Sloan-Kettering Cancer Center in New York: Drs Andrea Abramson, Linda LaTrenta, Laura Liberman, and Elizabeth Morris Their constant love, humor, devotion to quality, and good taste make each day at work special; without them, it never would have happened And to the Radiology Department at Memorial that has supported the academic endeavors of the Breast Imaging Section for many years, thanks again To our many fellows, who work so hard, ask so many difficult questions and keep us thinking, you are deeply appreciated, fondly remembered, and often missed Thanks to Beckie, Bruce, Brewster, John, Alan, and Andrea, who have made it possible to get through it all And for Ryan, a special thanks Ingrid Schreer would like to express her gratitude for the excellent collaboration within the multidisciplinary team of physicians, technologists, and other coworkers at the University of Kiel Special thanks go to the breast imaging team, in particular to Ms M Dickhaut and Ms A Große, who continuously supported the daily clinical and scientific work with all their effort and with empathy with the patients This work would not have been possible without them Deep appreciations go to Prof H.-J Frischbier, whose work and support constituted an essential basis for this book Sylvia H Heywang-Köbrunner, M.D D David Dershaw, M.D Ingrid Schreer, M.D VII Contents I Methods Patient History and Communication with the Patient Scheduling Patient Information 2 Patient History References Clinical Findings Visual Inspection Palpation 9 10 References Mammography Purpose, Accuracy, Possibilities, and Limitations Indications Accuracy Screening Problem Solving Mammographic Technique Components of the Mammographic Imaging Technique Specific Requirements and Solutions Image Sharpness Contrast Noise Radiation Dose Positioning and Compression Compression Positioning for Standard Views Positioning for Additional Views Film Labelling Spot Compression and Magnification Technique 13 14 14 14 14 15 15 16 17 26 26 27 36 36 39 39 41 45 50 52 Positioning of Breasts with Implants Specimen Radiography Quality Factors Hardware Factors that Influence Image Quality Influence of the Screen–Film System and Film Processing on Image Quality Quality Assurance in Mammography Reporting and Documentation Findings Clinical Findings Mammography Report Digital Mammography Galactography Appendix: Sonographic Imaging of Lactiferous Ducts Pneumocystography References 56 59 60 60 62 63 65 65 65 71 74 78 81 83 VIII Contents Sonography Purpose, Accuracy, Possibilities, and Limitations Diagnosing Cysts Differentiating Solid Lesions Diagnosing Carcinoma Younger Women Screening with Sonography Equipment Requirements Transducer 87 87 87 87 87 88 88 88 88 Image Quality 89 Examination Technique 92 Time-gain Compensation 92 Focusing 93 Examination Technique 93 Interpreting Sonographic Findings 96 Normal Sonographic Findings 96 Focal Sonographic Lesions 97 References 102 Magnetic Resonance Imaging (MRI) Purpose, Accuracy, Possibilities, and Limitations Accuracy Indications Technical Requirements Examination Procedure 103 103 104 106 108 103 Planning the Examination Examination Procedure Interpretation Criteria and Documentation of Findings Interpretation Criteria References Breast Imaging Techniques under Investigation Scintimammography 128 Positron Emission Tomography 129 128 132 132 132 133 134 135 135 Fine Needle Aspiration Core Needle Biopsy Vacuum-Suction Biopsy Ultrasound-Guided Biopsy Stereotactic Biopsy MR-Guided Percutaneous Biopsy References 136 137 137 140 141 146 150 136 136 Preoperative Localization Purpose, Definition, Indications, and Side Effects Methods and Technique Mammographically Guided Localization Techniques Ultrasound-Guided Localization 109 110 125 Other Methods 129 References 130 Percutaneous Biopsy Purpose Definitions Accuracy Possibilities and Limitations Contraindications Complications Patient Information, Patient Preparation, and Postbiopsy Care Techniques for Biopsy and Biopsy Guidance 108 109 152 152 153 153 155 MR-Guided Localization Galactographically Guided Localization Localization Materials Problems and Their Solutions References 157 158 158 159 160 Contents IX II Appearance The Normal Breast Anatomy The Adolescent Female Breast Histology Clinical Examination Mammography The Mature Female Breast Histology Sonography Clinical Examination Mammography Sonography Magnetic Resonance Imaging Involution Histology Clinical Examination Mammography Sonography Magnetic Resonance Imaging Abnormalities Asymmetry Clinical Examination Mammography Accessory Breast Tissue (Polymastia) Clinical Examination 162 162 163 163 163 163 163 163 163 163 165 166 168 170 170 170 170 170 170 171 171 171 171 173 173 Macromastia Clinical Examination Mammography Sonography Mammography Sonography and Magnetic Resonance Imaging Inverted Nipple Clinical Examination Mammography Sonography Magnetic Resonance Imaging Pregnancy and Lactation Histology Clinical Examination Mammography Breast Response with Hormone Replacement Therapy Sonography Magnetic Resonance Imaging Mammography Sonography Magnetic Resonance Imaging Percutaneous Biopsy References 10 Benign Breast Disorders Pathogenesis Incidence Histopathology Clinical Findings Diagnostic Strategy and Objectives 173 174 174 174 174 174 175 175 175 175 177 177 177 177 180 180 180 180 181 181 181 181 183 183 Mammography Sonography Magnetic Resonance Imaging Percutaneous Biopsy References 11 Cysts Histology Medical History and Clinical Findings Breast Examination Objectives of Diagnostic Studies Diagnostic Strategy Sonography 173 173 173 173 173 184 191 192 195 196 197 197 197 197 198 198 198 Aspiration of the Cyst Pneumocystography Mammography Magnetic Resonance Imaging Appendix: Galactoceles and Oil Cysts References 201 202 202 202 205 208 146 Percutaneous Biopsy light Roman a b c d e f Fig 7.12 a-f Images taken during a vacuum biopsy are shown a The scout view shows an indeterminate group of microcalcifications From the three views (- 15°, 0°, and + 15°) the 0° and the − 15° views were selected for planning the procedure b After planning, the needle, which is not yet fired, is introduced to the calculated „prefire“ position Its correct position is checked on this − 15° view c Correct „prefire“ position is also confirmed on the 0° view d, e After the needle is fired into the lesion, needle position is once more checked on the - 15° and 0° view f After withdrawing the needle, no more microcalcifications are visible at the biopsy site Histology revealed ductal carcinoma in situ, which was confirmed after re-excision magnification mammography is used, the lowest kVp and mAs settings on the unit should be used as the initial settings Specimen radiographs should be kept as part of the medical record A copy of the specimen radiograph may be appreciated by the pathologist As with ultrasound-guided biopsy, at the end of the procedure pressure should be held over the biopsy site to obtain hemostasis, the patient should be bandaged, and she should be given instruction on how to care for her breast after the biopsy and how she will receive the results lesions detected by MRI alone proves to be malignant.) Logistic problems due to difficult timing of MR localization procedure and surgery can be reduced Since enhancing lesions cannot usually be visualized in a specimen MRI, specimen X-ray, or sonogram, uncertainties concerning correct excision of lesions visualized by MRI only may remain after surgery Image-guided percutaneous removal could help to solve this problem í MR-Guided Percutaneous Biopsy Percutaneous biopsy of lesions, which are detected and only visible by MRI, is desirable for several reasons: − Open surgery of benign MR-detected lesions could be avoided (In most series out of 2−4 − − Presently, experience with percutaneous core biopsy has been reported by a few authors.62−66 Being a complicated procedure that is hampered by the inability to monitor the biopsy without major image artifacts, it has not been recommended for lesions cm and should still be considered to be “under development.” MR- Techniques for Biopsy and Biopsy Guidance 147 Fig.light 7.13 a−gRoman a Equipment for MR-guided localization, core needle or vacuum biopsy The housing of the biopsy coil is placed on the MR table The patient has to lie prone on this housing, and the pending breast will be moderately compressed between the two compression plates (arrows) A ring coil is inserted between the bars of the compression plates With her breast fixed, the patient has to lie still on this biopsy device throughout the procedure For imaging she is moved into the bore, for biopsy she is moved out of the magnet Based on the MR images, the transverse slice that contains the lesion can be identified This is aligned with the aiming device that supports the biopsy gun The height and depth of needle insertion is also determined from the transverse MR images and transferred to the aiming device That way, by setting the aiming device to the calculated coordinates the lesion will be pierced by the biopsy probe and centered exactly at the acquisition window of the probe b Close-up images of an MR-guided vacuum biopsy The ୴ patient lies prone on the biopsy coil The vacuum biopsy probe is inserted into the patient’s breast after the bars of the compression plate have been spread by a spacer Fig 7.13 c−g guided vacuum biopsy has proven much more promising, as confirmed by first experiences with over 200 examinations acquired in a European multicenter study67, 68(Fig 7.13) í Handling the Biopsy Specimen If the needle is removed from the breast and reinserted, care should be taken not to place the needle in preservative and reintroduce it into the ୴ breast (Fig 7.12) For fine needle aspirations, a new needle should be used for each aspiration If cores are undergoing specimen radiography, they should be kept moist with saline until they are placed in preservative so that drying artifact does not compromise the ability of the pathologist to make a diagnosis The pathologist should be supplied with adequate information to interpret the specimen The lesion should be described, and the suspected di- 148 Percutaneous Biopsy light Roman c d e f g Fig 7.13 c−g Representative images of an MR-guided vacuum biopsy In this patient MRI was performed due to impaired assessment after breast-conserving therapy, because of overlying tissue (other slices) and scarring A small enhancing focus was detected by MRI, which in retrospect could only be reproduced on one mammographic view c Precontrast MR image of the lesion d Postcontrast MR image The lesion enhances and becomes almost isointense to fat e Subtraction image of the lesion f Based on the imaging coordinates of the lesion, first a thin MR-compatible substitute needle is inserted to the calculated position and checked by MRI Then its correct position, which is shown here, is confirmed (in order to have the lesion at the acquisition chamber of the probe, the probe has to reach beyond the lesion) Then the patient is moved out of the MRI The substitute needle is exchanged against the vacuum probe, and vacuum biopsy is performed at the calculated position g Finally, correct removal is checked This image shows that the cavity is in the exact place where the lesion had initially been Histology: ductal carcinoma G2 Techniques for Biopsy and Biopsy Guidance 149 agnosis be included in the lesion descriplight should Roman tion If the lesion was calcifications the pathologist should be provided with the specimen radiograph or a copy Any pertinent clinical history should also be provided í Interpreting the Histologic Results A pivotal step in the successful application of these biopsy procedures to patient care is the correlation of the biopsy results with the imaging pattern of the targeted lesion This is the final determination of whether the suspicious lesion has been biopsied For lesions that are BIRADS category and have benign histopathologies that are concordant with the imaging pattern, the biopsy can be assumed to have been successful.27, 32 Concordance should, however, be checked very diligently in category lesions Furthermore, the type of biopsy (its reliability depending on the type of lesion), the individual accuracy of the radiologist (audit), and the success of the biopsy procedure (adequacy of the specimens, volume of tissue acquired, certainty or proof of correct needle placement or tissue acquisition, presence of hemorrhage) need to be taken into account For lesions that are BI-RADS category and have benign histopathologies, the need for rebiopsy should be strongly considered Although some entities, such as focal fibrosis and scar, can have a spiculated pattern, rebiopsy may be appropriate to be certain that carcinoma is not present.69 Certain histopathologies are consistent with the imaging pattern but can be part of a focus of disease within the breast that can contain more aggressive diseases than those diagnosed at the time of biopsy The most important of these is ductal atypia (atypical ductal hyperplasia, ADH), which is almost always evident as calcifications on mammography.48−51 In the transformation of ductal epithelium from normal to malignant, the transitional phase is ADH It may progress to ductal carcinoma in situ or to invasive cancer The presence of ADH in biopsied ducts raises the possibility that part of the ductal epithelium near this lesion may have progressed to ductal carcinoma in situ or even invasive carcinoma Furthermore, one focus of ADH may be indicative of multicentric disease which may be occult to imaging The likelihood that ductal carcinoma in situ may be present increases as smaller amounts of tissue are removed due to the increased possibility of sampling error with small amounts of tissue (see accuracy of core biopsy and vacuum-suction biopsy, p 134) Therefore, in all cases of core biopsy yielding a diagnosis of ductal atypia, surgical excision should be performed to evaluate for possible coexistent carcinoma Similar problems may occur, if ductal carcinoma in situ is diagnosed by percutaneous biopsy, since coexistent areas of invasive carcinoma can be present.52−55 As with ductal atypia, this is a function of a histologically heterogenous lesion Here, sampling at core biopsy may miss the most aggressive part of the lesion As with ductal atypia, these so-called “underestimates” decrease with increasing tissue volume sampled Since patients with ductal carcinoma in situ, like those with invasive carcinoma, always undergo surgical re-excision anyway, this has the following clinical significance: − − The need for possible surgical treatment or sampling of the axilla is not correctly assessed before re-excision of the lesion in those women with the incorrect diagnosis of ductal carcinoma in situ (instead of invasive carcinoma) Therefore, these women may need a second trip to the operating room for their axillary surgery after the final diagnosis of invasive carcinoma is established by surgical excision In some of these women, preoperative consultation may incorrectly advise them that adjuvant chemotherapy is unnecessary Radial scar has been reported to have coexistent carcinoma present in up to 25 % of cases This is usually located in the periphery of the lesion, and the cell type is usually tubular Therefore, diagnosis of radial scar obtained from percutaneous biopsy raises the possibility of coexistent carcinoma and should result in surgical excision of the site.69 Controversy has surrounded the management of women with a core biopsy diagnosis of lobular carcinoma in situ.70, 71 Because this lesion rarely has mammographic findings, it does not explain the cause of a mammographic abnormality that resulted in a biopsy recommendation Therefore, another entity should be sought to explain the formation of the suspicious lesion Without another reason for re-excision, lobular carcinoma in situ does not require wider, surgical excision However, it is a marker for increased risk to develop breast cancer, and referral of the patient for high-risk management should be considered 150 Percutaneous Biopsy Some Roman lesions will be difficult for the pathololight gist to diagnose based on tissue removed at core biopsy Such difficulties may occur in differentiating phyllodes tumor from fibroadenoma Furthermore, depending on the experience of individual pathologists, papillary lesions and lesions containing mucus may also be difficult for some pathologists to definitively diagnose as benign based on core specimens.72 Finally other rare lesions can also be difficult for the pathologist to diagnose by core biopsy The pathologist should note this difficulty in the pathology report and recommend surgical excision When this occurs, patient management should be based on the pathologist’s recommendation, and surgical excision of the lesion should be performed 14 15 16 17 18 19 20 í References 21 22 10 11 12 13 Azavedo E, Svane G, Auer G Stereotactic fine-needle biopsy in 2594 mammographically detected non palpable lesions Lancet I 1998;1033−6 Pisano ED, Fajardo LL, Tsimikas J et al Rate of insufficient samples for fine-needle aspiration for nonpalpable breast lesions in a multicenter clinical trial: The Radiologic Diagnostic Oncology Group study Cancer 1998;82:678−88 NHS Breast Screening Programme Guidelines for Cytology Procedures and Reporting in Breast Cancer Screening: Report by Cytology Sub-Group of the National Coordinating Committee for Breast Screening Pathology; NHSBSP Publication N 22; Sept 1993 Marcaccio MJ, O’Brien SE, Chen VS Fine-needle aspiration cytology in breast lumps Can J Surg 1986;29:405−7 Dent DM, Kirkpatrick AE, McGoogan E, Chetty U, Anderson TJ Stereotaxic localization and aspiration cytology of impalpable breast lesions Clin Radiol 1989;40:380−2 Dowlatshahi K, Yaremko ML, Kluskens LF, Jokich PM Nonpalpable breast lesions: Findings of stereotaxic needlecore biopsy and finde-needle aspiration cytology Radiology 1991;185:639−40 Dempsey P, Rubin E The roles of needle biopsy and periodic follow-up in the evaluation and diagnosis of breast lesions Semin Roentgenol 1993;28:252−8 Maestro C, Giudicelli T, Ettore F et al Ultrasound-guided cytopuncture of impalpable solid breast lesions J Radiol 1994;75:497−503 Saalrela AO, Kiviniemi HO, Rissanen TJ, Paloneva TK Nonpalpable breast lesions: pathologic correlation of ultrasonographically guided fine-needle aspiration biopsy J Ultrasound Med 1996;15:549−53 Lofgren M, Andersson I, Lindholm K Stereotactic fineneedle aspiration for cytologic diagnosis of nonpalpable breast lesions AJR 1990;154:1191−5 Sarfati MR, Fox KA, Warneke JA et al Stereotactic fineneedle aspiration cytology of nonpalpable breast lesions: an analysis of 258 consecutive aspirates Am J Surg 1994;168:529−31 Britton PD Fine needle aspiration or core biopsy Breast 1999;8:1−4 Britton PD, McCann J Needle biopsy in the NHS Breast Screening Programme 1996/97: How much and how accurate? Breast 1999;8:5−11 23 24 25 26 27 28 29 30 31 32 33 Brenner RJ, Fajardo L, Fisher PR et al Percutaneous core biopsy of the breast: effect of operator experience and number of samples on diagnostic accuracy AJR 1996;166:341− Liberman L, Evans WP, Dershaw DD et al Specimen radiography of microcalcifications in stereotaxic mammary core biopsy specimens Radiology 1994;190:223−5 Parker SH, Lovin JD, Jobe WE et al Nonpalpable breast lesions: stereotactic automated large-core biopsies Radiology 1991;180:403−7 Elvecrog EL, Lechner MC, Nelson MT Nonpalpable breast lesions: correlation of stereotactic large-core needle biopsy and surgical biopsy results Radiology 1993; 188:453−5 Gisvold JJ, Goellner JR, Grant CS et al Breast biopsy: a comparative study of stereotaxically guided core and excisional techniques AJR 1994;162:815−20 Dershaw DD, Morris EA, Liberman L, Abramson AF Nondiagnostic core breast biopsy: results of rebiopsy Radiology 1996;198:323−5 Britton PD, Flower CD, Freeman AH et al Changing to core biopsy in an NHS breast screening unit Clin Radiol 1997;52:764−7 Fornage BD, Coan JD, David CL Ultrasound-guided needle biopsy of the breast and other interventional procedures Radiol Clin North Am 1992;30:167 Schulz-Wendtland R, Kramer S, Lang N, Bautz W Ultrasonic guided microbiopsy in mammary diagnosis: indications, technique and results Anticancer Res 1998; 18:2145−6 Parker SH, Jobe WE, Dennis MA et al US-guided automated large-core breast biopsy Radiology 1993;187:507− 11 Fajardo LL, Jackson VP, Hunter TB Interventional procedures in diseases of the breast: Needle biopsy, pneumocystography and galactography AJR 1992; 158:1231−8 Nguyen M, Mc Combs MM, Ghandehari S et al An update on core needle biopsy for radiologically detected breast lesions Cancer 1996;78:2340−5 Frayne J, Sterrett GF, Harvey J et al Stereotactic 14 gauge core-biopsy of the breast: results from 101 patients Aust N Z J Surg: 1996;66:585−91 Lee Ch, Egglin TK, Philpotts LE et al Cost-effectiveness of stereotactic core needle biopsy: analysis by means of mammographic findings Radiology 1997;202:849−54 Liberman L, Dershaw DD, Glassman JR et al Analysis of cancers not diagnosed at stereotactic core breast biopsy Radiology 1997;203:151−7 Acheson MB, Patton RG, Howisey RL et al Histologic correlation of image-guided core biopsy with excisional biopsy of nonpalpable breast lesions Arch Surg 1997;132:815−8 and 819−21 Fuhrman GM, Cederbom GJ, Bolton JS et al Image-guided core needle breast biopsy is an accurate technique to evaluate patients with nonpalpable imaging abnormalities Ann Surg 1998;227:932−9 Meyer JE, Smith DN, Lester SC et al Large core needle biopsy: nonmalignant breast abnormalities evaluated with surgical excision or repeat core biopsy Radiology 1998;206:717−9 Jackman RJ, Nowels KW, Rodriguez-Soto J et al Stereotactic, automated, large-core needle biopsy of nonpalpable breast lesions: false-negative and histologic underestimation rates after long-term follow-up Radiology 1999;210:799−805 Parker SH, Burbank F, Jackman RJ et al Percutaneous large-core breast biopsy: a multiinstitutional study Radiology 1994;193:359−64 Techniques for Biopsy and Biopsy Guidance 151 34 light Nath ME, Robinson TM, Tobon H et al Automated largeRoman core needle biopsy of surgically removed breast lesions: comparison of samples obtained with 14, 16, and 18 gauge needles Radiology 1995;197:739−42 35 Mainiero MB, Philpotts LE, Lee CH et al Stereotaxic core needle biopsy of breast microcalcifications: correlation of target accuracy and diagnosis with lesion size Radiology 1996;198:665−9 36 Lee CH, Philpotts LE, Horvath LJ et al Follow-up of breast lesions diagnosed as benign with stereotactic core-needle biopsy: frequency of mammographic change and falsenegative rate Radiology 1999;212:189−94 37 Meyer JE, Smith DN, Dipiro PJ et al Stereotactic breast biopsy of clustered microcalcifications with a directional, vacuum-assisted device Radiology 1997;204:575−6 38 Liberman L, Smolkin JH, Dershaw DD et al Calcification retrieval at stereotactic 11-gauge vacuum-assisted breast biopsy Radiology 1998;208:251−60 39 Liberman L, Dershaw DD, Rosen PP et al Percutaneous removal of malignant lesions at stereotactic vacuum-assisted biopsy Radiology 1998;206:711−5 40 Heywang-Köbrunner SH, Schaumlöffel U, Viehweg P et al Minimally invasive stereotactic vacuum core breast biopsy Eur Radiol 1998;8;377−85 41 Götz L, Amaya B, Häntschel G et al Mammographically guided vacuum biopsy: experiences with 700 cases Eur Radiol 2000;10(suppl):329 42 Jackman RJ, Marzoni FA, Nowels KW Percutaneous removal of benign mammographic lesions: comparison of automated large-core and directional vacuum-assisted biopsy techniques AJR 1998;171:1325−30 43 Zannis VJ, Aliano KM The evolving practice pattern of the breast surgeon with disappearance of open biopsy for nonpalpable lesions Am J Surg 1998;176:525−8 44 Philpotts LE, Shaheen NA, Carter D et al Comparison of rebiopsy rates after stereotactic core needle biopsy of the breast with 11-gauge vacuum suction probe versus 14gauge needle and automatic gun AJR 1999;172:683−7 45 Reynolds HE, Poon CM, Goulet RJ, Lazaridis CL Biopsy of breast microcalcifications using an 11-gauge directional vacuum-assisted device AJR 1998;171:611−3 46 Liberman L, Hann LE, Dershaw DD et al Mammographic findings after sterotaxic 14-gauge vacuum biopsy Radiology 1997;203:243−7 47 Berg WA, Krebs TL, Campassi C et al Evaluation of 14- and 11-gauge directional, vacuum-assisted biopsy probes and 14-gauge biopsy guns in a breast parenchymal model Radiology 1997;205:203−8 48 Burbank F Stereotactic breast biopsy of atypical ductal hyperplasia and ductal carcinoma in situ: improved accuracy with a directional, vacuum-assisted biopsy instrument Radiology 1997;202;843−8 49 Jackman RJ, Burbank F, Parker SH et al Atypical ductal hyperplasia diagnosed at stereotactic breast biopsy: improved reliability with 14-gauge, directional, vacuum-assisted biopsy Radiology 1997;204:485−8 50 Liberman L, Cohen MA, Dershaw DD et al Atypical ductal hyperplasia diagnosed at stereotaxic core biopsy of breast lesions: an indication for surgical biopsy AJR 1995;164:1111−3 51 Brem RF, Behrndt VS, Sanow L, Gatewood OMB Atypical ductal hyperplasia: histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy AJR 1999;172:1405−7 52 Won B, Reynolds H, Lazaridis CL, Jackson VP Stereotactic biopsy of ductal carcinoma in situ using an 11 gauge vacuum-assisted device: persistent underestimation of disease AJR 1999;173:227−9 53 Götz L, Amaya B, Häntschel G et al Comparison between histologic outcome in vacuum biopsy and re-excision Eur Radiol 2000;10(suppl1):2−10 54 Jackman RJ, Burbank FH, Parker SH et al Accuracy of sampling ductal carcinoma in situ by three stereotactic breast biopsy methods (abstr) Radiology 1998;209(P):197−8 55 Liberman L, Dershaw DD, Rosen PP et al Stereotactic core biopsy of breast carcinoma: accuracy at predicting invasion Radiology 1995;194:379−81 56 Liberman L, Dershaw DD, Rosen PP et al Core-needle biopsy of synchronous ipsilateral breast lesions: impact on treatment AJR 1996;166:1429−32 57 Rosenblatt R, Fineberg SA, Sparano JA, Kaleya RN Stereotactic core needle biopsy of multiple sites in the breast: efficacy and effect on patient care Radiology 1996;201:67−70 58 Krämer S, Schulz-Wendtland R Experiences with 400 core needle biopsies Publication in preparation Personal communication (April 2000) 59 Dershaw DD Percutaneous biopsy of nonpalpable breast lesions: core or fine needle aspiration In: Interventional Breast Procedures Dershaw DD, ed New York: Churchill Livingstone; 1996:103−6 60 Burbank F, Forcier N Tissue marking clip for stereotactic breast biopsy: initial placement accuracy, long-term stability, and usefulness as a guide for wire localization Radiology 1997;205:407−15 61 Liberman L, Dershaw DD, Morris EA et al Clip placement after stereotactic vacuum-assisted breast biopsy Radiology 1997;205:417−22 62 Heywang-Köbrunner SH, Hyynh AT, Viehweg P, Hanke W, Requardt H, Paprosch I Prototype breast coil for MRguided needle localization J Comput Assist Tomogr 1994;18:876−81 63 Orel SG, Schnall MD, Newman RW, Powell CM, Torosian MH, Rosato EF MR imaging-guided localization and biopsy of breast lesions: initial experience Radiology 1994;193:97−102 64 Fischer U, Kopka L, Grabbe E Magnetic resonance guided localization and biopsy of suspicious breast lesions Top Magn Reson Imaging 1998;9:44−59 65 Kuhl, C, Elevelt A, Leutner C, Gieseke J, Pakos E, Schild H Interventional breast MR imaging: clinical use of a stereotactic localization and biopsy device Radiology 1997;204:667−75 66 Heywang-Köbrunner SH, Heinig A, Pickuth D, Alberich T, Spielmann RP Interventional MRI of the breast: lesion localization and biopsy Eur Radiol 2000;10:36−45 67 Heywang-Köbrunner SH, Heinig A, Schaumlöffel U et al MR-guided percutaneous excisional and incisional biopsy of breast lesions Eur Radiol 1999;9:1656−65 68 Perlet C, Sittek H, Prat X et al Multicenter Study for evaluation of a new device for localisation and biopsy of MRdetected lesions RoFo submitted (Study supported by EC Biomed project) 69 Liberman L, Dershaw DD, Rosen PP et al Stereotaxic core biopsy of impalpable spiculated breast masses AJR 1995;165:551−4 70 Liberman L, Sama M, Susnik B et al Lobular carcinoma in situ at percutaneous breast biopsy: surgical biopsy findings AJR.1999;173:291−9 71 Gabriel H The dilemma of lobular carcinoma in situ at percutaneous biopsy: to excise or to monitor AJR 1999; 173:300−2 72 Liberman L, Bracero N, Vuolo MA et al Percutaneous large-core biopsy of papillary breast lesions AJR 1999; 172:331−7 152 Roman 8.lightPreoperative Localization Purpose, Definition, Indications, and Side Effects í Purpose í Definition The increasing use of mammography has resulted in an increased rate of detection of clinically occult disease Lesions requiring surgical excision that are only detected in diagnostic imaging studies, i e., nonpalpable lesions, must be localized for the surgeon Nonpalpable lesions can be localized under mammographic or ultrasound guidance or, less frequently, under CT or MRI guidance For image-guided localization only those imaging modalities should be chosen that clearly show the lesion When several modalities fulfill this requirement, the modality that allows the fastest and easiest approach should be chosen There are several mammographically guided preoperative localization methods They differ with respect to their technical requirements, the time required, their precision, and thus their accuracy.1, Lesions that can be unequivocally identified by sonography can also be localized under sonographic guidance On the whole, precision requires as much experience for ultrasound-guided localization as does mammographically guided localization Ultrasound-guided localization of sufficiently large lesions can usually be performed more quickly than mammographic localization by experienced personnel Lesions that are only detected by contrast-enhanced MRI must be marked using contrast-enhanced MRI or CT MR- or CT-guided localization can be performed with acceptable accuracy (ȗ to 10 mm) with the patient supine similar to the standard CT-guided biopsy of other organs Special biopsy coils for percutaneous biopsy to mark lesions that were detected in MRI studies are meanwhile available and allow much better accuracy Preoperative localization refers to marking a nonpalpable lesion detected in a diagnostic imaging study for subsequent excision í Indication Any nonpalpable lesion requiring excision detected by mammography, sonography, or magnetic resonance imaging must be preoperatively localized and marked for the surgeon Reliable excision and histologic examination of nonpalpable lesions can only be performed after such lesions have been correctly marked Preoperative localization also enables the surgeon to excise a lesion with the removal of a minimal volume of breast tissue, minimizing postsurgical deformity í Side Effects The following side effects are possible: – – – Pain Bleeding Vasovagal reaction3 The major pain perceived by the patient is felt during insertion of the needle through the skin itself Advancing the needle or wire through the breast or injecting contrast solution (dye or carbon) is generally much less painful The compression required in mammographically guided localization is also generally well tolerated, even with the needle in place This assumes, of course, that the examiner proceeds gently Bleeding is only a problem when an artery is inadvertently injured during localization If this occurs, firm compression has to be applied for a sufficient period of time (approximately 10 min) Methods and Technique 153 The physician light Roman must always be prepared for vasovagal reactions since individual tolerance to the introduction of a needle into the breast varies greatly Methods and Technique í Mammographically Guided Localization Techniques Before any preoperative localization, the radiologist should review the imaging studies to be certain a lesion exists and requires excision Although lesions seen only on one view can be localized with stereotactic technique, an effort should be made to assess a lesion fully on two orthogonal views before scheduling needle localization For this purpose it is recommended that a mediolateral or lateromedial view be obtained to supplement the craniocaudal and mediolateral oblique views The true lateral gives a better sense of the depth of the lesion in the breast and thus helps to improve orientation Because the patient needs to cooperate during the localization procedure, she should not be premedicated Local anesthetic is not given because its instillation is usually more painful than the insertion of a localizing wire into the breast í Localizing Lesions Using a Perforated or Marked Compression Plate Depending on the position of the lesion and the chosen way of access, a craniocaudal, caudocranial, mediolateral, or lateromedial view is obtained using a perforated plexiglass compression plate (Fig 8.1) or a fenestrated compression plate with alphanumeric markings along its edge The needle is to be inserted through the perforated or fenestrated compression plate and perpendicular to it An initial image is taken with the patient’s breast in compression between the localization plate On this film the lesion must be imaged within the fenestration The patient is held in compression while the film is developed The point of needle insertion on the skin is chosen according to the coordinates of the lesion with reference to the markings The skin over the lesion is cleansed and the needle is inserted into the breast, parallel to the chest wall It is inserted beyond a depth calculated on the second orthogonal view, or as deep as possible if this depth cannot be exactly determined on the initial view The needle should pass far enough through the lesion so that its tip will still penetrate the lesion after compression is removed and the breast relaxes Next, a mammogram in the second orthogonal imaging plane is obtained After this image compression on the breast is maintained Based on this image, the depth of needle insertion is adjusted, if necessary Once the needle is in the correct position, the wire is deployed or a marker solution injected Correct needle insertion or correct placement and distribution of the marker solution is then also documented in two planes before the patient is sent to the operating room The advantage of this method is that it can easily be performed even by minimally experienced personnel and without expensive equipment Because the approach is parallel to the chest wall, patients should never develop a pneumothorax The most relevant disadvantage is that it requires purchase of perforated or fenestrated plates If so desired, an approach that approximates the probable surgical one can usually be achieved by careful selection of the initial plane of compression that is decisive for the direction of needle insertion Even though the surgeon can approach a localized lesion independent of the position of the wire, some prefer to follow the path of the wire for the excision í Stereotactic Localization The accuracy that can be achieved with this procedure is comparable to that using a perforated compression plate, provided sufficient experience of possible pitfalls exists and the procedure is performed diligently This is due to various hazards (see below) and the failure to readjust the needle depth on a second, orthogonal view before final deployment The procedure is the same as in a stereotaxic biopsy (see p 144−7) Once the correct position of the needle is verified, a marker wire is placed or a contrast solution injected The needle usually just acts as a guide for 154 Preoperative Localization light Roman R ML cranial Direction of puncture Direction of puncture R CC lateral Fig 8.1 a–c Schematic diagram of manual localization: The coordinates of the lesion in the horizontal (CC view) and vertical (ML view) direction (a and b) with reference to the nipple are marked on the skin of the breast and the depth of the lesion from the skin surface is measured a b R L c Fig 8.2 Perforated compression plate for localizing breast lesions the wire and needs to be removed before releasing the compression on the breast If the needle is to stay in place, an appropriate opening in the needle holder is necessary to allow detaching of the needle from it First the needle is placed in the same manner as for stereotaxic percutaneous biopsy After the wire is placed, the proper position is first documented in the usual stereotaxic views (+ 15° and – 15°) After compression is released we strongly recommend that the correct wire placement be further documented in another plane perpendicular to the primary imaging plane (for example, in the mediolateral plane, if the first plane was the CC plane; Figs 8.2 a–e) This is important because, particularly in dense breasts, tissue elasticity can cause the tip of the Methods and Technique 155 needle lie above the lesion, not readily aplight toRoman parent in the stereotaxic views A positioning error of a few millimeters in a compressed breast can correspond to a large positioning error ( cm) in the relaxed breast To minimize the upward displacement of the needle that often occurs as a result of tissue elasticity, the needle may be placed 3–6 mm deeper than the calculated target point This compensates for tissue elasticity, and once compression is relieved, the needle will usually lie at the desired location For localization, the stereotaxic method is comparable to localization procedures using a perforated compression plate The major importance of stereotaxy is its use for percutaneous biopsy The following special problems can occur in stereotaxic needle localization: – – Due to the geometry of stereotaxy, slight deviations in the position of the needle in the targeting or documentation views can correspond to a significant deviation in depth localization Localization errors can occur if the patient moves (in nondigital systems significant time may elapse for development of the localization views and for depth determination), or if the targets chosen on the + 15° and – 15° stereotaxic views prove not to be identical This may occur with ill-defined lesions, for which it is difficult to identify the same structure on the + 15° and – 15° views or with multiple microcalcifications showing minimal pleomorphism Even with the tip of the needle in the correct position, inserting the marker wire will usually push the denser breast tissue forward a few millimeters The resulting positioning error in the compressed breast can result in a final positioning error in the relaxed breast of over cm To minimize these problems, the following steps are recommended: – – – – Exercising extreme care in selecting the target point and in verifying it in the + 15° and – 15° views Switching to another localization method if identical target points cannot be clearly located on the compression views Always advancing the needle a few millimeters deeper than the target point to compensate for tissue elasticity Always verifying the final result in two perpendicular planes – Always (with this method) using localization needles that can be repositioned in case of an unsatisfactory position í Manual Localization Manual localization was the first and simplest method for advancing a needle to a lesion under mammographic guidance In most institutions, it has been replaced by the grid technique since an approach parallel to the chest wall is preferred In the hands of an experienced radiologist it may, however, allow a fast approach to superficial lesions and to lesions which may be difficult to localize by the standard methods (retroareolar lesions) The advantages are the simplicity and the fact that the point of entry lies directly anterior to the lesion, which often corresponds to the approach preferred by the surgeon Disadvantages are that it is generally not as precise as localizing with add-on devices with the necessity for corrections in a certain percentage of lesions, and it requires more practice and skill in three-dimensional visualization than other methods of localization Finally, the axis of the needle is perpendicular to the chest wall, increasing the risk of injury to the chest wall when a lesion is located posteriorly Procedure: Figure 8.3 shows how the point of entry on the skin is selected based on the mammograms and how the depth of the lesion is measured When transferring the coordinates of the lesion with respect to the nipple, the assistant must be careful to hold the breast in the same position as it was in the original mediolateral view When inserting the needle, the physician places his or her other hand around the tissue into which the needle is to be inserted This minimizes the risk of injury to the chest wall and brings the breast into a shape similar to that on the mediolateral view The position of the needle is then verified in mammograms in two planes (craniocaudal and 90° mediolateral) and corrected if necessary After verification of the correct needle position, a contrast solution is injected or a wire is placed through the needle í Ultrasound-Guided Localization Ultrasound-guided localization requires that the lesion be visualized via sonography This means that it cannot be used with microcalcifications, yet it is very effective in localizing focal lesions The procedure is similar to the ultrasound-guided per- 156 Preoperative Localization light Roman a b c Fig 8.3 a–e a Two partial views with the tube tilted – 15° and + 15° reveal a small focal lesion requiring localization or biopsy b Demonstrating the tip of the needle in the center of the focal lesion c and d Documentation view demonstrating correct positioning of the localization wire e Specimen radiography Methods and Technique 157 light Roman e d cutaneous biopsy (see p 140-1) Instead of aspirating or performing a core biopsy, the radiologist deploys a marker wire through the needle Contrast solutions are not generally used in ultrasoundguided localization Sonographic verification of the correct needle position is mandatory (Fig 8.4) The advantage of ultrasound-guided localization over other methods of localization is that it takes the least amount of time A disadvantage is that visualization of small or preinvasive lesions may be uncertain or impossible Furthermore, it may sometimes be difficult to identify the lesion in a subsequent specimen sonogram í MR-Guided Localization Lesions detected by MRI alone must be preoperatively marked using contrast-enhanced MRI or contrast-enhanced CT Ultrasound-guided localization by a physician experienced in both sonog- Fig 8.4 Documenting correct positioning of the needle after ultrasound-guided localization The tip of the needle is visible as a hyperechoic point in the center of the lesion Definite localization of the needle-tip position requires visualization of the needle in its long axis 158 Preoperative Localization raphy MRI is recommended only where sublightandRoman sequent sonograms unequivocally demonstrate a lesion correlating with lesion the detected by MRI Due to respiratory motion, a lesion detected by MRI can be localized with an accuracy of ȗ cm using a CT or MRI unit without a special biopsy coil Highly precise preoperative marking (and localization for core biopsy) is possible through the use of special “biopsy” or “localization” coils Various devices for MR-guided localization are meanwhile available The exact procedure varies with the device.4−10 í Galactographically Guided Localization If a lesion is only detected at galactography, repeat galactography will be required for preoperative localization of the lesion í Technique Several options for galactographically guided localization are available: After galactography (see Chapter 3, p 74−80) in the craniocaudal and mediolateral planes, the galactographic findings are localized using the standard mammographic localization techniques (i e., manually, using a perforated plate, or by means of stereotaxy) If only a single duct is involved, the duct may be galactographically visualized and delineated immediately preoperatively using a combination of contrast medium and patent blue The blue-dyed ductal system must be excised immediately after instillation of contrast medium In the presence of significant duct ectasia, the lactiferous duct itself will sometimes be visible at mammography or sonography In this case, mammographic or ultrasound localization is possible without the use of contrast media Localization Materials The selection of localization materials depends on the interval between localization and surgery Usually, localization is performed shortly before surgery In this case, some physicians elected to use low-cost dye marking with patent blue immediately preoperatively Having verified correct needle position, the radiologist injects 0.2–0.3 ml of blue dye, such as methylene blue or patent blue, after which the surgeon removes the bluestained parenchymal tissue For mammographically guided localization, the radiologist adds 0.2–0.3 ml of a nonionic radiographic contrast medium This is necessary for subsequent documentation of proper dispersion of the contrast solution on the two-view mammogram done after the localization has been completed It is important to perform the surgery as quickly as possible after injecting the blue solution because within a few hours the solution can diffuse throughout large areas of the breast or even the entire breast, rendering precise localization impossible If the interval between administration of the contrast solution and surgery cannot be limited to a few hours, the radiologist should choose a different localization procedure Further disadvantages are that diffusion renders it impossible for the pathologist to identify the exact injection site, and in addition to contrast allergies, severe allergies to patent blue, although rare, have been known to occur Another simple procedure is to use a carbon solution for marking the lesion The advantage of carbon is that it does not diffuse Therefore it can be performed several days preoperatively since the carbon remains at the injection site until the surgeon removes it along with the lesion However, even though inert and harmless, carbon solution is not approved in some countries (USA) for use in the breast This method has mainly been used for CT- and MR-guided localization since in these cases it is often difficult to coordinate the scheduling of the examination and surgery The sterile carbon solution, which can be prepared by most pharmacies (4 g of activated charcoal in 100 ml of 0.9% saline solution), in injected into the center of the lesion to be excised or directly proximal to it Approximately 1–1.5 ml of solution have to be injected to achieve sufficient dispersion and visualization For mammographically guided localization, 0.2–0.3 ml of nonionic radiographic contrast medium should be added to the solution for subsequent image documentation of correct dispersion Then a fine line of carbon extending all the way to the skin is injected as the needle is withdrawn, to permit the surgeon to locate the lesion after the needle or wire has been removed A particular advantage of this method is that the carbon also enables the pathologist to locate the injection site in the specimen Methods and Technique 159 Some Roman surgeons prefer to have the needle left light in place (suitable only if the mammography suite is close to the operating room) or have a marker wire placed through the localization needle to facilitate locating the lesion, which may be stained with dye or unstained Today localization wires are mostly used They have the advantage of being more flexible and better anchored in the tissue This minimizes the risk of wire migration There are various types of localization wires (Fig 8.5) The tenacity of staying in place varies with their shape and the type of breast tissue Dislocation can occur particularly in soft fatty tissue, whereby dislocation primarily occurs in the soft, fatty tissues In rare cases, wires have been observed to migrate distally This usually occurs only in wires whose form predisposes them to migrate in a certain direction, such as a simple 1shaped hookwire The so-called twist marker (which can also be retracted through tissue like a corkscrew), the Homer wire, and the Fixmarker (from BIP) are nondirectional The particular advantage of these wires is that they can be withdrawn or retracted through the needle, making it possible to correct the position of the needle at any time Regardless of the wire chosen, the physician should ensure that the needle through which the wire is advanced is sufficiently stiff (it should not be too thin and flexible) because otherwise it can deviate considerably in dense tissue and seriously compromise the accuracy of localization An adequate length of wire should extend beyond the skin and be securely taped to it to avoid retraction of the wire and its subsequent loss During surgery, if the surgeon is dissecting along the length of the wire, he or she should be careful not to transsect it It may then retract into the breast and be very difficult to locate Problems and Their Solutions All methods require documentation of the final position of the localization wire or the contrast solution This means that after mammographically guided localization, the position of the needle should be documented in two mammographic planes (craniocaudal and mediolateral) If the wire is improperly positioned but the distance between the tumor and the tip of the wire is still acceptable (i e., does not exceed 10 mm), the radiologist may describe to the surgeon the exact Fig 8.5 Various localization wires position of the lesion in the image with respect to the tip of the wire Large areas undergoing excision should have their margins marked with two wires Multiple lesions can be needle localized for excision in one surgical procedure Wires rather than dye should be used in this setting to avoid staining large areas of the breast The exact position of the wire or contrast solution should also be documented in MR-guided and ultrasound-guided localization If improper positioning occurs, the necessary corrections should be discussed with the surgeon, assuming of course that the deviation is within acceptable limits Sufficient experience and thorough discussion of the results are essential because precise localization is unfortunately not always possible Furthermore, it is not always easy for the surgeon to find the contrast solution or marker wire, particularly 160 Preoperative Localization in light large breasts Roman Perioperative or intraoperative dislocation of the wire may occur Close cooperation between radiologist and surgeon is essential for effective management, i e., removal of the suspicious lesion with the smallest possible volume of breast tissue Correct excision of microcalcifications and nonpalpable lesions detected at mammography should also be documented by specimen radiography.11 Lesions detected only at sonography should be documented by specimen sonography whenever possible í References í Summary The increasing use of mammography has resulted in an increased rate of detection of clinically occult lesions These lesions must be marked for the surgeon to ensure that they can be effectively removed Several methods are available Accepted methods involve use of a perforated or marked compression plate, stereotaxy or in selected cases manual localisation Focal lesions with correlating sonographic findings or focal lesions detected only at ultrasonography can be quickly and reliably marked using ultrasound-guided localization Localization techniques guided by magnetic resonance imaging permit accurate marking of lesions that are detected only at MRI and require excision CT-guided localization after administration of contrast remains an alternative for marking nonpalpable MRI-detected lesions that are also visible by contrast-enhanced CT but not by conventional imaging It is faster and easier than MR localization without a dedicated biopsy coil Due to the significant radiation dose and the lower accuracy, CT-guided localization should, however, in the future be replaced by MRguided localization using dedicated coils The choice between needle marking, wire marking with various marker wires, or marking with carbon or methylene blue depends on the time interval between localization and surgery, the conditions under which the patient must be transported to the operating room and the surgeon’s preferences 10 11 Bauer M, Schulz-Wendtlandt R Stereotaktische Lokalisation kleinster Mammaläsionen für Diagnostik und präoperative Markierung – Methodik, experimentelle Untersuchungen und klinische Ergebnisse bei 217 Patientinnen Fortschr Rontgenstr 1992;156:286–90 Homer MJ, Smith TJ, Safaii H Prebiopsy needle localization Methods, problems and expected results In: Radiol Clin North Am Breast imaging: current status and future directions 1992;30(1):139–53 Helvie MA, Ikeda DM, Adler DD Localization and needle aspiration of breast lesions: complications in 370 cases AJR 1991;157:711–14 Heywang-Köbrunner SH, Requardt H, Huynh AT et al MRI of the breast: first experiences with a new localisation device Eur Congr Radiol 1993;93:204 Heywang-Köbrunner SH Work in progress: Prototype breast coil for MR-guided needle localization – first experiences J Comput Assist Tomogr 1994;18:876–81 Heywang-Köbrunner SH, Beck R Contrast-enhanced MRI of the Breast 2nd ed Berlin: Springer; 1996 Orel SG, Schnall MD, Newman RW et al MR imagingguided localization and biopsy of breast lesions: Initial experience Radiology 1994;193:97–102 Fischer U, Kopka L, Grabbe E Magnetic resonance guided localization and biopsy of suspicious breast lesions Top Magn Reson Imaging 1998;9:44−59 Kuhl C, Elevelt A, Leutner C, Gieseke J, Pakos E, Schild H Interventional breast MR imaging: clinical use of a stereotactic localization and biopsy device Radiology 1997;204:667−75 Heywang-Köbrunner SH, Heinig A, Pickuth D, Alberich T, Spielmann RP Interventional MRI of the breast: lesion localization and biopsy Eur Radiol 2000;10:36−45 Graham RA, Homer MJ, Sigler CJ, Safaii H, Schmid CH, Marchant DJ, Smith TJ The efficacy of specimen radiography in evaluating the surgical margins of impalpable breast carcinoma AJR 1994;162:33–6 ... and Objectives 17 3 17 4 17 4 17 4 17 4 17 4 17 5 17 5 17 5 17 5 17 7 17 7 17 7 17 7 18 0 18 0 18 0 18 0 18 1 18 1 18 1 18 1 18 3 18 3 Mammography Sonography Magnetic Resonance. .. Accessory Breast Tissue (Polymastia) Clinical Examination 16 2 16 2 16 3 16 3 16 3 16 3 16 3 16 3 16 3 16 3 16 5 16 6 16 8 17 0 17 0 17 0 17 0 17 0 17 0 17 1 17 1 17 1 17 1 17 3 17 3 Macromastia... Breast Examination Objectives of Diagnostic Studies Diagnostic Strategy Sonography 17 3 17 3 17 3 17 3 17 3 18 4 19 1 19 2 19 5 19 6 19 7 19 7