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Sonography-guided interventions in breast

Erster Gemeinsamer Senologie Kongress der Deutschen-Österreichischen-Schweizer Gesellschaft für Senologie. Lugano (sur invitation)

D. FOURNIER, MD,
Institut de Radiologie, CH-1950 Sion, Switzerland

Imaging guided percutaneous procedures become more and more important in non surgical differentiation of benign and malignant processes. The goal of this approach is the reduction in the surgical procedures for benign lesions. US guided is the simpliest way to guide and a very important application of US for breast imaging

US-guided interventions are :

• Cyst aspiration
• Abscess drainage
• Fine-needle/core-biopsy
• Presurgical localization

Indications for cyts aspiration are mass other than simple cyst, palpable/non-palpable cyst causing tenderness, palpable/non-palpable cyst near implants and chest wall (to avoid complications of non guided aspiration), palpable cyst in anxious patient.

Indications for FNA/ large-core needle biopsy are mass thought to be malignant (to do one-stage surgical procedure), multiple masses (to facilitate treatment planning), probably benign lesion, fibroadenoma (after 35 y.o or atypical FA), hypoechoic structure other than simple cyst (complex cyst, fibroadenoma, papilloma, circumscribed carcinoma), indeterminated but probably benign mass. We recommand to look at microcalcifications with US because they may be associated with US abnormality (mass, attenuation, hypervascularity) that gives a target for FNA/core biopsy US-guided.

FNA-technique is simple using free hand approach, 21-23 gauge needle, aspirating gun. Since 1996, we use Cytolyt ® for cells preservation ; one of the multiple advantages of this method is to be independant of bloody contamination.

FNA give a reliable diagnostic of malignancy if performed by experienced sonologist/cytologist. Difficulties are encoutered with fibrosis, fat necrosis infiltrating lobular carcinoma which are better sampled with core biopsy.

The choice between large-core biopsy or FNA depends of your experience and of the review of cytologic or pathologic findings to evaluate the success of each procedures in your hands. You should consider the preferences and expertise of your pathologist too.

Compared to stereotaxy, advantages of US for large-core needle biopsy are : choice in positioning the patient, more comfortable, real time observation of the needle, more quickly done, less bleeding than stereotaxic biopsies, lower cost.

Presurgical localization with needle hook wires using US localization rather than fenestrated mammographic plate or stereotaxic device has many advantages : supine position as for surgery, the approach is the shortest distance, quicker, less discomfort, lower cost. Indications for presurgical localization with US are masses or other lesion that can be imaged with US particularly those inaccessible to mammographic fenestrated-plate localization/stereotaxy, far posteriorly and in the axillary tail

Summary

US-guided interventions have many advantages and rare complications compared to other imaging techniques. But successful FNA/large core biopsy needs to be familiar with US appearance of breast lesions, to have experience with US-guided procedures, to be inside the lesion with the needle, to have a good aspiration technique, to preserve the material for the cytopathologist, to have a high degree of collaboration/experience with the cytopathologist
In good hands FNA/large core biopsy may eliminate the need for surgical biopsy but remember that this way is not helpful if it does not shorten the diagnostic process. In our practice, cost-benefit rate is for sonography-guided FNA.

References

• Echographie du sein diagnostique et interventionnelle, J Michelin, L Levy, Masson, 1999
• Syllabus : a categorical course in breast imaging, RSNA 1995
• Stratégie diagnostique en sénologie, C Frouge, Masson 1995
• Imagerie du sein, Y Grumbach, SFR, 1996
• W.Ph Evans, 1995 RSNA, abstract.

Présenté à (sur invitation) :
Erster Gemeinsamer Senologie Kongress der Deutschen-Österreichischen-Schweizer Gesellschaft für Senologie. Lugano. (2000)