Ultrasound Guided Breast Biopsies

Introduction

Hello, my name is Isabel Newton and I'm an interventional radiologist and breast imager at the VA in San Diego and University of California, San Diego. Today I'm going to talk to you about ultrasound-guided breast biopsies.

Objectives

  • To review the indications for ultrasound-guided breast biopsy
  • To discuss basic and advanced techniques in ultrasound-guided biopsy in the breast and lymph nodes
  • To review risks and alternatives, which are important for the consent process

Topics

Indications for Ultrasound-Guided Breast Biopsy

Indications for an ultrasound-guided biopsy of the breast include:

  • BI-RADS 4 or 5 lesion that is new and must be visible on ultrasound.
  • Additional area of concern in a patient with known breast cancer (BI-RADS 6 lesion).
  • Abnormal lymph nodes, whether inside the breast (intramammary) or in the axilla in patients with or without known breast cancer.
  • Reactive lymph nodes in patients who have recently received the COVID-19 vaccine.

Tools for Ultrasound-Guided Biopsy

Essential tools include:

  • High-Quality Ultrasound: Typically a linear high-frequency transducer, with occasional use of lower frequency or curvilinear transducers for deeper tissues.
  • Biopsy Devices: Vacuum-assisted biopsy devices (9 gauge) for larger tissue samples and core biopsy devices with coaxial needles for greater control and fewer skin passes.
  • Lidocaine: Buffered with bicarbonate to reduce stinging, and lidocaine with epinephrine to reduce bleeding risk.
  • Other Tools: Francine needle for FNA samples, spinal needle for deeper numbing or hydrodissection.

Biopsy Procedure Technique

The procedure involves several key steps:

  • Review Imaging: Ensure correct spot and side for biopsy.
  • Obtain Consent: Explain procedure, risks, and alternatives to the patient.
  • Ultrasound Before Prepping: Plan the best approach without drapes.
  • Timeout: Ensure correct patient, side, and readiness of equipment.
  • Clean and Drape: Ensure plenty of space for the planned approach.
  • Numb the Skin: Use lidocaine around and underneath the mass.
  • Approach the Mass: Use a parallel trajectory to avoid sensitive areas.
  • Take Sufficient Samples: Typically 3-6 samples using coaxial technique.
  • Place Sample in Correct Solution: Usually formalin, but RPMI for suspected lymphoma or sterile cup for microbiology.
  • Place a Clip: If patient consents, use coaxial needle for clip placement.
  • Post-Biopsy Imaging: Use color Doppler to assess for bleeding or complications.

Risks and Alternatives

Key risks and alternatives include:

  • Risks: Bleeding, infection, damage to surrounding tissues, pain, clip migration, and non-diagnostic biopsy.
  • Alternatives: Short interval follow-up with imaging, surgical excision.

Consent Process

The consent process is vital for patient comfort, autonomy, and understanding. It involves:

  • Explaining the procedure, risks, and alternatives.
  • Addressing patient concerns and ensuring they understand what to expect.
  • Using a compassionate approach to promote patient understanding and ease.

Conclusion

In review, we've discussed the indications for ultrasound-guided breast biopsy, basic and advanced techniques, risks and alternatives, and the importance of a thorough consent process. Thank you for your attention.