Interventional Ultrasound of the Breast: From Biopsy to Ablation

Preface
Note to the Reader
Acknowledgments
Contents
1: Equipment for Breast Ultrasound
	Transducers
	Techniques Designed to Expand the US Field of View (FOV)
		Extended FOV Sonograms
		Electronic Beam Steering and Trapezoidal FOV
	Color and Power Doppler Imaging
	Real-Time Spatial Compounding
	Tissue Harmonic Imaging
	Three-Dimensional US
	Automated Breast US
	Portable Laptop and Tablet/SMARTPHONE-BASED Scanners
	Elastography
	Contrast-Enhanced US
	Other Useless “Breakthrough” Imaging Techniques that Have Fallen (or Will Fall) into Oblivion
	References
2: Basic Breast Ultrasound Examination Technique
	General Considerations
	Position of the Patient
	Position of the Sonologist
	Selection of the Transducer
	Grayscale Settings
	Image Format and Size
	Color Doppler Settings
	Correlation of US with Mammography and Other Imaging Modalities
		Lesion’s Location
		Shape
		Size
		Tissular Environment
	Correlation Between US and Palpation Findings
	Special US Examination Technique for Lesions Seen on Only One Mammographic View
	Dynamic Maneuvers
	Documentation
	References
3: General Considerations in Ultrasound-Guided Percutaneous Needle Biopsies
	Why a Percutaneous Breast Biopsy?
	Who Performs Percutaneous Breast Biopsies?
	Three Fundamental Steps of Percutaneous Needle Biopsy
	Target Selection
	Timing of Biopsy
	Communication with the Pathologist
	Why the Epidemic of US-Guided Breast Biopsies?
	References
4: Preparing for Ultrasound-Guided Biopsy
	Patient Evaluation by Nurse
	Role of US Technologist
	Informed Consent
	Time-Out Procedure
	Patient Positioning
	Proceduralist Positioning
	Probe Selection
	US Guidance for Palpable Masses?
	Selection of Biopsy Type
	References
5: Basic Needle Insertion Techniques
	Anatomy of US Scan Plane
	In-Plane Needle Insertion Technique
		For FNA
		For CNB
	Vertical or Out-of-Plane Needle Insertion Technique
	How to Hold the Probe and Biopsy Needle
	Freehand Technique
	Documentation of Freehand US-Guided Procedures
	Use of Needle Attachments
	Training in Freehand Technique
	Electronic Assistance Devices
	References
6: Fine-Needle Aspiration
	Equipment Needed for FNA
		Transducer
		Preparation of the Patient
		Tray for FNA
		Needles
		Syringes
		Material for Slide Preparation
	FNA Procedure
		Assessment of Patient
		Skin Disinfection
		Local Anesthetization
		Needle Insertion
		Documentation
	Aspiration of Solid Masses
	How Many FNA Passes Are Necessary?
	Nondiagnostic FNA Specimens
	Placement of a Metallic Marker
	Preparation and Processing of Specimen
		Aspirate Recovery
		Smear Technique
		Slide Fixation
		Slide Staining
		Liquid Specimen Preparation
		Special Techniques to Enhance Cytological Diagnosis
	Teamwork OF FNA
	Postprocedural Care
	Reporting the Preliminary Cytological Diagnosis
	References
7: Fine-Needle Aspiration of Cysts and Other Fluid Collections
	Simple Cysts
	“Non-simple” Cysts
		Inspissated Cysts
		Clusters of Microcysts
		Complex Cysts
		Inflammatory Cysts
		Outside FNA Report Mentions “Atypical” Cells
	Cysts with Intracystic Neoplasms
	Oil Cysts
	Galactoceles
	Other Fluid Collections
		Postoperative Collections
			Hematomas and Seromas
			Lymphoceles
			Periprosthetic Collections
		Abscesses
	References
8: Fine-Needle Aspiration of Solid Masses
	Benign Masses
		Fibroadenomas
		Lipomas and Fat Lobules
		Hamartomas (Fibroadenolipomas)
		Fibrocystic Changes
		Fat Necrosis
		Acute Inflammation, Mastitis, and Cellulitis
		Intramammary Lymph Nodes
		Papillary Lesions
		Lactational Changes
		Rare Benign Lesions Presenting as Masses
		Benign High-Risk Lesions
		Skin Lesions
			Sebaceous Cysts
			Epidermal Inclusion Cysts
			Pilomatricoma
		Gynecomastia
		Accessory Breast Tissue
	Malignant Tumors
		Ductal Carcinoma In Situ (DCIS)
		Invasive Breast Cancer
			Less Common Invasive Cancers
			Inflammatory Breast Cancer
			Male Breast Cancer
		Local Recurrences
		Metastases to the Breast
		Lymphoma and Leukemia
	References
9: Fine-Needle Aspiration in Breast Cancer Staging
	LOCAL STAGING
		US Examination
		FNA Versus CNB
		Multifocal Disease
		Multicentric Disease
		US Versus Magnetic Resonance Imaging
	REGIONAL STAGING
		General Considerations in US-Guided FNA of Lymph Nodes
		US Characteristics of Lymph Node Metastases
			Grayscale US
				Deformity of the Node
				Marked Decrease in Echogenicity of Intranodal Metastatic Deposits
				Lymph Node Metastases from Lobular Carcinoma
				Microcalcifications in a Node
			Power Doppler US
			Elastography
		Which Node to Target?
		Where to Sample Within the Abnormal Node
		FNA or CNB?
		Isolated Tumor Cells and Micrometastases
		Placement of Tissue Marker in FNA-Proven Axillary Node Metastasis
		Impact of an FNA-Positive Regional Node on the Cancer Stage
		Axillary Nodes
			Anatomy
			US Examination
			US-Guided FNA Technique
			Impact of Positive FNA of an Axillary Node
			Differential Diagnosis of Indeterminate Axillary Nodes
		Intramammary Nodes
		Supraclavicular Nodes
		Cervical Nodes
		Internal Mammary Nodes
			Anatomy
			US Examination
			IM Nodal Metastases
			Differential Diagnosis of Indeterminate IM Nodes
			US-Guided FNA Technique
			Impact of Positive FNA of an IM Node
			Patient Selection
		Contralateral Nodes
		Should Patients with DCIS Be “Staged” with US?
		Summary
	DISTANT METASTASES AND OTHER LESIONS DETECTED DURING US STAGING
		Metastases to Muscles
		Bone Metastases
		Metastases to Other Organs
		Miscellaneous Benign Lesions
	References
10: Advantages and Limitations of Ultrasound-Guided Fine-Needle Aspiration
	Advantages of US-Guided FNA
		Accuracy
		Safety
		Extensive Sampling of Solid Masses
		Simplicity
		Aspiration of Fluid and Injection of Air or Contrast Material
		Excellent Tolerance with Extremely Rare Complications
		Rapid Availability of Results
		Low Cost
	Limitations of US-Guided FNA
		Requirement of an Expert Cytopathologist
		Requirement of an Expert Interventional Breast Imager
		Difficulty Sampling Paucicellular Masses
		Inability to Determine Invasiveness of a Cancer
	References
11: Errors and Pitfalls in Ultrasound-Guided Fine-Needle Aspiration
	Poor US Visualization of Lesion Detected with Another Modality
	Multiple Potential Targets on US
	Ballistic Errors
	Aspiration of Least Cellular Part of Target
	Poor Aspiration Technique
	Nondiagnostic Specimens
	Errors in Cytopathological Interpretation
		False-Negative Diagnoses of Breast Cancer
		False-Positive Diagnoses of Breast Cancer
	Avoiding Pitfalls
		The Rule of Concordance
		Teamwork
	References
12: Core-Needle Biopsy
	CNB Devices
		Spring-Activated Cutting Devices
			CNB Devices Using a Standard Tru-Cut Needle
				Fully Automatic Devices
				Delayed Automatic Devices
				Zero-Throw Mode
				Manual Devices
				Bent Stylet
			CNB Systems Using a Cylindrical Cutting Cannula
				Argovac
				BioPince
		Non-Spring-Activated CNB Devices
			Cassi II Biopsy System
			NeoNavia System
	WhicH Needle Gauge to Use?
		Historical Perspective
		Our Experience at MD Anderson
	Preparation for CNB
		Sterile Tray
		Patient Assessment
		Positioning of Equipment
	Disinfection of the Skin
	US-Guided Local Anesthesia
	Technique of US-Guided CNB
		Planning the Needle’s Trajectory
		Needle Insertion
		Optimizing Needle Visibility
		Firing the Biopsy Gun
	Documentation
	Needle Removal and Core Recovery
	Coaxial CNB Technique
	Where to Shoot?
	How Many Cores Should Be Taken?
	“Needle-Bending” Artifact
	Processing the Cores
		Standard Recovery and Transfer of Cores to the Pathology Department
		Special On-Site Processing of Cores
			Imprint (Touch-Prep) Cytology
			Radiographs of Cores
	Errors and Pitfalls in CNB
		Only Part of the Needle Shaft (Not Its Tip) Is Displayed on Longitudinal Sonograms
		Volume Averaging Artifact
	Indications and Contraindications for US-Guided CNB
		What to “Core” with US Guidance
		What Not to “Core” with US Guidance
			Architectural Distortions
			Small Clusters of Microcalcifications
			Very Small Targets Near Critical Structures
	Role of the Technologist in the Decision to Biopsy
	Role of the Patient in the Decision to Biopsy
	Skin BIOPSY WITH CNB DEVICE
	Placement of a Metallic Tissue Marker
	Post-CNB Care and Instructions
	References
13: Vacuum-Assisted Biopsy
	History of VAB
	Current VAB Devices
		Miniaturized Battery-Powered VAB Devices
		Single-Core VAB Devices
	Standard Technique of US-Guided VAB
	Advantages of VAB
	Limitations of VAB
	When to Use US-Guided VAB?
	References
14: Choosing the Biopsy Technique
	MD Anderson Approach
		When the Presence of Fluid Is Suspected
		When a Suspicious Solid Mass Is Present
		When a Fibroadenoma-like Lesion Is Present
		When an Expert Cytopathologist Is Not Available
	Bigger Is Not Better
	Points to Remember
	References
15: Biopsy Markers
	Background and Rationale
	Currently Available Biopsy Markers
		Plain Metallic Markers
			Metallic Markers Placed After VAB
			Ultraclip Markers
			Embolization Coil
			UltraCor Twirl
			Tumark
		Markers Specifically Designed for US Visibility
			SecurMark
			Gel-Based and Other Polymer-Based Markers
				HydroMark
				Beacon
				BioMarC
	Marker Placement
		Markers Deployed After VAB
		Markers Deployed After CNB or FNA
		Post-procedural Mammograms
	Do We Need to Place a Marker After Every US-Guided Needle Biopsy?
	Overuse of Markers
	Problems Associated with Biopsy Markers
		Non-visibility of Markers on US
		Confusion Between Multiple Markers Placed in the Same Breast
		Migration of Markers
		Breaking Off of the Marker
		Safety of Markers
		Pain
		Intraoperative US Localization of a Marker That Is Missing on Specimen Radiographs
		Transection of a Metallic Marker During Sectioning of the Surgical Specimen
		Intraoperative Loss of the Marker
		Empty Applicator
		Biopsy Marker Becomes a Suspicious Target
	Biozorb Marker
	Ideal Biopsy Marker
	References
16: Complications of Percutaneous Needle Biopsy
	Pain
	Hemorrhagic and Vascular Complications
		Hematomas
		Pseudoaneurysms
		Mondor’s Disease
	Infection
	Damage to Breast Implants
	Pneumothorax
	Milk Fistulas
	Malignant Seeding Along the Needle Track
	Injuries to the Operator
	Interference of Post-biopsy Changes with Subsequent Imaging
	Psychological Impact of Breast Biopsy on Patients
	References
17: What Not to Biopsy
	General Requirements for US-Guided Needle Biopsies
	Factors Leading to Unnecessary US-Guided Biopsies
		Lack of Expertise in Interpreting Breast Sonograms
		Assumption That a Breast Biopsy Is Harmless
		Breast Imager’s Fear of Missing a Cancer
		Patient Anxiety
		Other Factors
	Cost of Unnecessary Breast Biopsies
	Solutions
		Adequate Training in Breast US
		Mentoring and Coaching
		Dedicated Subsection of Interventional Breast US Imagers
		Follow-Up Imaging Recommendations When a Biopsy Is Not Done
	What Not to Biopsy
		Lesions That Are Not “Real”
		Lesions Whose US Appearance Is 100% Benign in Patients Without a History of Breast Cancer
		Other Examples of Lesions That Should Not Be Biopsied
	Reference
18: Keys to Success in Ultrasound-Guided Breast Biopsy
	Practice on Phantoms
	Communication with an Experienced Breast Pathologist
	Teamwork
	Concordance Between Imaging Findings and Biopsy Result
	Reporting
	Careful Target Selection
19: Ultrasound-Guided Localization of Nonpalpable Lesions
	Needle and Wire Localizations
	Localization with Colored Substances
		Dyes
		Carbon Black Suspension
		Limitation
	Radioactive Seed Localization
		Seeds
		Technique of US-Guided RSL
		Using More than One Seed
		Advantages
		Limitations
		Complications and Other Problems
			Before Seed Placement
			During Seed Placement
			Between Implantation and Surgery
			During Surgery
	Other Techniques of Localization Using Radioactive Substances
		Radioguided Occult Lesion Localization (ROLL)
		Sentinel Node and Occult Lesion Localization (SNOLL)
	Skin Marking
	Localization with US in the OR
		Historical Perspective
		Logistical Requirements
		Technique of IOUS Localization
		Advantages of IOUS Localization
			“Rescue” IOUS Localization by the Breast Imager
			US Examination of the Surgical Specimen
			IOUS-Guided Excision of Nonpalpable Masses by the Surgeon
			Cryoprobe-Assisted Lumpectomy
	Emerging Localization Techniques
		Magnetic Seed Localization
		Localization Using a Magnetic Occult Lesion Localization Instrument (MOLLI)
		Localization Using Radio Waves and Infrared Light
		Localization Using Radiofrequency Identification Tags
	References
20: Other Ultrasound-Guided Interventional Procedures
	Percutaneous Ductography
	Injection of Radionuclide for Lymphoscintigraphy and Sentinel Node Biopsy
	Sentinel Node Identification with Contrast-Enhanced US
	Placement of Brachytherapy Devices in the Postoperative Cavity
	References
21: Percutaneous Ablation of Breast Masses
	General Considerations
	Techniques of PA
		Thermotherapy Techniques
			RFA
			Laser-Induced Hyperthermia
			Microwave Thermotherapy
			HIFU
		Cryoablation
			Instrumentation
			Mechanisms of Action
			Technique of US-Guided Cryoablation
			Advantages of Cryoablation Over Thermotherapy
			Trial Results
		Irreversible Electroporation
	Questions and Concerns About US-Guided PA of Breast Cancer
		Inability to Determine Margin Status After PA
		Who Is a Candidate for PA?
		What Follow-Up Is Needed After PA?
		Long-Term Cosmetic Results
		More Studies Are Needed to Optimize the Parameters Used for PA Techniques
		Long-Term Disease Control
		Operator-Dependence and Required Expertise in US-Guided Interventions
		Who Should Perform PA?
	References
Index