Background. Mammotome is a percutaneous biopsy technique with a large needle, assisted by vacuum aspiration. The single insertion technique allows to collect multiple large tissue samples, which gives a more reliable histological result. The technique can be used under stereotactic, MRl or ultrasound guidance. The technique is used under local anesthesia, on an outpatient basis. Conclusions. Altough it is essentially a diagnostic technique, it has a therapeutic potential in some cases. Recently, the technique has been FDA approved for the removal of benign nodular lesions. Worldwide, over 2 million procedures have already been performed. It has the potential to replace surgical open biopsy, with a similar accuracy and at a lower cost, and it is less invasive

Caselmann, Jan

Steyaert, Luc

van Kerkhove, Filip

English

Digital repository of Slovenian research organizations

Rndiol Oncol 2004; 38(Suppl 1): S153-S7. Vacuum biopsy of the breast Experience of St-J an Hospital in Brugge Luc Steyaert, Filip Van Kerkhove, Jan Casselman Department of Radiology-Medical Imaging, St-Jan Hospital, Brugge, Belgium Background. Mammotome is a percutaneous biopsy technique with a large needle, assisted by vacuum as­piration. The single insertion technique allows to collect multiple large tissue samples, which gives a more reliable histological result. The technique can be used under stereotactic, MRI or ultrasound guidance. The technique is used under local anesthesia, on an outpatient basis. Conclusions. Altough it is essentially a diagnostic technique, it has a therapeutic potential in some cases. Recently, the technique has been FDA approved far the removal oj benign nodular lesions. Worldwide, over 2 mil/ion procedures have already been performed. It has the potential to replace surgical open biopsy, with a simi/ar accuracy and at a lower cost, and it is less invasive. Key words: breast, vacuum biopsy, mamomat, stereotactic guidance, MRI, ultrasound Technique and procedure The Mammotome needle comes in 3 sizes (14, 11 and 8 G) and has a double aspiration sys­tem. The tip is either blunted or bladed; the latter facilitates the insertion between tissue planes. An advantage of the system is that a single insertion allows retrieval of multiple (theoretically unlimited) samples.1Once the needle correctly positioned, the needle opens, tissue is aspirated in the biop­sy window, and a cylinder is cut by a rotating knife. By retracting the inner part of the nee­dle, the tissue sample is retrieved, while the needle stays in accurate position. Correspondence to: Luc Steyaert, Dept. of Radiology­Medical Imaging, St-Jan Hospital, B-8000 Brugge, Belgium; Phone:+32 50 45 21 00; E-mail: luc.steyaert@azbrugge.be The average weight of the cores is higher than a standard biopsy: 300 mg (8G), 100 mg (llG) or 35mg (14G) compared to 17mg for a 14G core biopsy. By retrieving several samples, it is possible to remove completely a nodular lesion up to 2.5-3 cm; the 8G needle is best suited for these larger nodules. The disposable needle is mounted on a handheld device, that is connected to a com­puter controlled unit by mechanical and elec­trical cables, and 2 vacuum lines. The differ­ent functions of the device are commanded by footswitches, and a screen allows to have visual control over the procedure. The biopsy is done under local anaesthesia and requires a small skin incision of 4-Smm. The precise application of anaesthesia deeper around the lesion facilitates the insertion and accurate placement of the large needle. The S154 Steyaert Let ni/ Vncuum biopsy oj the brenst needle is placed under the lesion that has to be biopsied, so that we have a good vision on the lesion and the needle; in some cases a lat­eral placement is required to avoid skin aspi­ration; the advantage of ultrasound guidance is the possibility to monitor in real tirne, and to have longitudinal or transverse imaging. In case of bleeding, the vacuum allows to aspi­rate the blood.2•3 After retracting the needle, manual local compression is applied to prevent haematoma formation. The incision is carefully closed with Dermabond® in order to have rninimal scar. The average procedure tirne is 30-40min. Indications The main indication of Mammotome is biop­sy of clustrers of rnicrocalcifications, which is usually done under stereotactic guidance. This method has a largely proven reliability and should replace surgical open biopsy. The most convenient and most comfort­a ble way to do this procedure is on a prone table. We use the Fischer table for our proce­dures. The patient is lying cornfortably in a prone position, without seeing the procedure itself, which is more relaxing. The biopsy can be performed from almost any direction, 360° around the breast, and there is the possibility of frontal and lateral approach, so that virtu­ally any lesion in the breast can be reached with the Mammotome needle. The table is equipped with a digital spot Mammography, which speeds up the procedure, since we have nearly instant visualisation. Under MRI guidance, the technique has in­dications in the diagnosis of suspicious en­hancing lesions, which has no clear expression on mammography or ultrasound. The proce­dure is lengthier than the US or Mammo­graphy guided one, and requires special equipment. The ultrasound guided procedure is stili some matter of discussion, but should also re-Radiol Oncol 2004; 38(Suppl 1): S153-S7. place surgical biopsy for nodular lesion, and replace even surgery for complete removal of certain types of benign lesions.4 In our experience, the main indications are:5 Probably benign ar indeterminate nodular lesions Most frequent indications are palpable or non palpable nodular lesions or areas of tissue changes (Birads 4 and 3). We always try to remove the lesion completely so that there is no uncertainty on later control images.6 In our experience, the psychological impact of the complete removal is very important in re­assuring the patient. Very small suspicious lesion Lesions <5mm can sometimes be difficult to biopsy with standard core biopsy; Mammo­tome allows a more certain histological result. Lesions in difficult location The absence of a forward throw of the needle reduces the risk of touching sensitive struc­tures; we recommend the use of Mammo­tome in lesions close to the nipple, the tho­racic wall, the skin or the axillary region. Areas of localised attenuation Most of the tirne, these are caused by areas of fibrosis, but localised attenuation can be the only sign of an invasive lobular carcinoma. A large sampling is recommended in these cases. Isolated, complex fibrocystic areas Only a large histological sampling allows a correct histological differentiation7 between fibrocystic changes, atypia and in situ carci­noma; in our experience, all of these tissue changes are sometimes present in the same area. Steyaert Let ni/ Vacuum biopsy oj the breast S155 Papillomas Small solitary papillomas can be accurately diagnosed and removed using Mammotome. In our experience and according to recent lit­erature, 8 clinical manifestations also disap­pear after complete removal. Clusters oj microcalcifications Many clusters are visible on ultrasound. In difficult locations, where stereotactic proce­dure is hazardous, like close to the nipple, to the skin, or the axillary region, ultrasound guidance offers a reliable and secure alterna­tive because of the real time monitoring.9Very hard lesions, with inconclusive previous biopsy ar FNAC Due to the vacuum aspiration and the rotat­ing cutter, even in the hardest lesions, where adequate sampling with core fails, good his­tological results are obtained with Mammo­tome. Removal oj benign lesions Breast lesions, certainly when they are palpa­ble, cause a lot of uncertainty and anxiety to the patient; inconclusive reports aggravate these conditions; a strong family history of cancer is also an aggravating factor. Because we always have to consider the attitude of the patient in the presence of a breast lesion, fre­quently the decision is made to surgically re­move a lesion. Mammotome can be a better and less expensive alternative.6,10 Recently, FDA approved the use of the device far this purpose. Lesions up to 2.5-3 cm can be completely removed with minimal or no scarring. The technique is very well supported by the pa­tients. Discussed indications: radia/ scar, large intracystic lesions Small radia! scars, without associated nodu­lar centre on ultrasound, are less frequently associated with malignancy than previously thought. Although a Mammotome biopsy can establish a correct diagnosis, the biggest in­convenient is that the pathologist misses the integrity of the lesion. This is also the case far larger papillary intracystic lesions. Results W e use Mammotome far nearly 5 years now and have perfarmed around 1300 procedures; this represents about 30% of our breast biop­sies. The majority of the biopsies are done with core needle, most 16 or 18G; FNAC is rarely used far solid lesions because of the limited infarmation. About 48% of the Mammotome procedures are done under stereotactic guidance, 45% un­der ultrasound, and 7% under MRI (this rela­tively high percentage is explained by the fact that we are the only centre in the country that is equipped far MRI-guided procedures). In the mammographic cases, 29% malignan­cies and 7% of atypical ducal hyperplasia were faund; 64 % of the cases were benign, which eliminated the need far short term fallow-up. Of the malignant cases 88.7% were in situ car­cinomas! W e only had 2 false negative results in the beginning, mainly due to inexperience. The ultrasound cases showed give a lower number of malignant cases, which is normal, due to the type of indications. We had 16% malignancies, 4% atypia and 80% benign le­sions. If we do not take in account the fi­broadenomas removed "on request" (as an al­ternative far surgery), and if we consider pa­pillomas as "postive" cases, we had 64% be­nign and 36% of positive biopsies. The MRI-guided procedures resulted in 32% malignant, 2% of atypia and 66% of be­nign cases. Radio/ Oncol 2004; 38(Suppl 1): S153-S7. S156 Steyaert L et a// Vacuum biopsy of the breast Conclusions Overall, Mammotome is a very reliable sam­pling technique,11 with very few complica­tions, is relatively easy to use, and well sup­ported by the patients. Compared to surgical biopsy, the cost is 2 to 3 times lower, even without counting the additional "social" cost.12 Because it is less invasive, it can be used more easily, thus reducing the cost of repetitive con­trols or more expensive additional exams, and above ali it reduces the tirne between detection and diagnosis, which is very important in reas­suring the patient; it can also have a prognostic impact since tumours can be diagnosed in an earlier stage; delayed diagnosis, with potential medico-legal impact, can also be avoided. The technique can at this moment not be considered as therapeutic in case of malig­nancy. In our hospital, the use of Mammotome radically changed the approach of breast pathology. Detection of lesions is done by (full field digital) Mammography frequently combined with high resolution ultrasound; MRI is done only in limited cases. In the presence of an abnormality, no control exams are done, but we try to provide an histological proof, most of the tirne immediately follow­ing the diagnostic imaging. W e usually have a definitive histological report within 24 to 48 hours. This gives high patient satisfaction and considerably reduces patient anxiety. Ultrasound guided core biopsy is the most frequently used procedure; Mammotome is reserved for more difficult lesions and for mi­crocalcifications. Surgical open biopsy has virtually been eliminated in our hospital. There is practically no more surgery for be­nign lesions. In case of malignancy, a one step therapeutic operation can be planned, with a fully informed patient. Due to the high number of small lesions and in situ lesions, breast conserving surgery and sentinel node procedure are done in a majority of cases. Radio/ Oncol 2004; 38(Suppl 1): S153-S7.All cases are discussed in a multi-discipli­nary team, which meets weekly. The use of Mammotome is in our experience an important addition in our daily practice. References -L. Wilson R. Large core biopsy techniques of the breast.IBUS 92-96; 2000. 2. Parker SH, Klaus AJ, McWey PJ, Schilling KJ,Cupples TE, Duchesne N, et al. Sonographically guided directional vacuum-assisted breast biopsyusing a handheld device. AJR Am J Roentgenol2001; 177: 405-8.3. Johnson AT, Henry-Tillman RS, Smith LF,Harshfield D, Korourian S, et al. Percutaneous ex­cisional breast biopsy. Am J Surg 2002; 184: 550-4.4. Meloni GB, Dessole S, Becchere MP, Soro D,Capobianco G, Ambrosini G, et al. Ultrasound­guided mammotome vacuum biopsy for the diag­nosis of impalpable breast lesions. Wtrasound Obstet Gynecol 2001; 18: 520-4.5. Steyaert L, Rigauts H. Prfl?vements assistt's par aspiration, sous guidage t'chographique. J Le Sein 2003; 13: 201-2. 6. Fine RE, Whitworth PW, Kim JA, Harness JK,Boyd BA, Burak WE Jr. Low-risk palpable breast masses removed using a vacuum-assisted hand­held device. Am J Surg 2003; 186: 362-7.7. Hung WK, Lam HS, Lau Y, Chan CM, Yip AW.Diagnostic accuracy of vacuum-assisted biopsy de­vice for image-detected breast lesions. ANZ J Surg 2001; 71: 457-60. 8. Dennis MA, Parker S, Kaske TI, Stavros AT, CampJ. Incidenta] treatment of nipple discharge causedby benign intraductal papilloma tluough diagnos­tic Mammotome biopsy. AJR Am J Roentgenol 2000; 174: 1263-8. 9. Steyaert L, Van Slambrouck K, Ghekiere J, Delanote J, Rigauts H. Feasability of ultrasoundguided Mammotome, biopsy for microcalcifica­tions: report of 31 cases. Proceedings of the 3rd EU­SOBI Congress, 12 -14 September 2001, Stockholm,Sweden.10. Fine RE, Boyd BA, Whitworth PW, Kim JA,Harness JK, Burak WE. Percutaneous removal ofbenign breast masses using a vacuum-assistedhand-held device with ultrasound guidance. Am JSurg 2002; 184: 332-6.5teyaert L et al / Vacuum biopsy of the breast S157 11. Brem RF, Schoonjans JM, Sanow L, GatewoodOM. Reliability of histologic diagnosis of breastcancer with stereotactic vacuum-assisted biopsy.Am 5urg 2001; 67: 388-92.12. Bonnaerens J. Multicenter survey in Belgium: lota/cost of surgical breast biopsy. 1999.Radio/ Oncol 2004; 38(Suppl 1): 5153-57. 

Vacuum biopsy of the breast

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Vacuum biopsy of the breast

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