MRI-Guided 9-Gauge Vacuum-Assisted Breast Biopsy: Initial Clinical Experience

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MRI-Guided 9-Gauge Vacuum-Assisted Breast Biopsy: Initial Clinical Experience

Laura Liberman, Nanette Bracero, Elizabeth Morris, Cynthia Thornton and D. David Dershaw

Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021.

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Fig. 1A —46-year-old woman with prior left mastectomy who had suspicious right breast mass on MRI examination performed for high-risk screening. MRI-guided biopsy device is inserted into breast to acquire tissue specimens.

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Fig. 1B —46-year-old woman with prior left mastectomy who had suspicious right breast mass on MRI examination performed for high-risk screening. Small skin nick is present after MRI-guided vacuum-assisted biopsy (arrow), which is managed with sterile strips and a sterile gauze bandage.

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Fig. 2A —59-year-old woman with recently diagnosed contralateral (left) breast invasive lobular cancer, who had suspicious right breast mass on MRI examination to assess for other sites of cancer in ipsilateral and contralateral breasts. Axial localizing image from MRI performed on day of biopsy. Vitamin E marker (arrow) has been placed on skin overlying lesion site, based on review of prior diagnostic MRI. Coil (Biopsy Breast Array Coil, MRI Devices) has breast support that displaces contralateral breast posteriorly, enabling access to medial or lateral skin surface with patient prone. Coil is also useful for patients with thin breasts; placing grids medially and laterally enables grid on far side to function as "reverse compression paddle," enabling biopsy device to displace tissue into opening of the grid on far side without piercing skin on far side.

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Fig. 2B —59-year-old woman with recently diagnosed contralateral (left) breast invasive lobular cancer, who had suspicious right breast mass on MRI examination to assess for other sites of cancer in ipsilateral and contralateral breasts. Sagittal T1-weighted contrast-enhanced scout images show irregularly marginated, irregularly shaped, rim-enhancing mass measuring 0.7 cm in right breast 12 o'clock axis, corresponding to lesion identified on diagnostic MRI examination. This could not be seen with mammography or directed sonography.

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Fig. 2C —59-year-old woman with recently diagnosed contralateral (left) breast invasive lobular cancer, who had suspicious right breast mass on MRI examination to assess for other sites of cancer in ipsilateral and contralateral breasts. Sagittal T1-weighted contrast-enhanced images show how radiologist determines skin-entry site and depth of insertion of needle. Image on left is same contrast-enhanced sagittal T1-weighted scout image showing the lesion in B, with cursor (x) placed over lesion. Image on far right shows vitamin E marker, with different cursor (o) placed over it. Image in center is skin surface, which is identified by indentations from grid lines, evident as low signal-intensity lines like a tic-tac-toe board. By correlating location of cursors over lesion and vitamin E marker on middle image, skin-entry site of needle (i.e., appropriate square and location within square of grid) is determined. Depth of needle insertion is equal to distance between skin (sagittal slice with low signal intensity lines) and lesion; this is determined by multiplying number of sagittal slices between skin and lesion by slice thickness (3 mm).

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Fig. 2D —59-year-old woman with recently diagnosed contralateral (left) breast invasive lobular cancer, who had suspicious right breast mass on MRI examination to assess for other sites of cancer in ipsilateral and contralateral breasts. Sagittal T1-weighted contrast-enhanced image of low signal intensity obturator in region of high signal intensity lesion.

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Fig. 2E —59-year-old woman with recently diagnosed contralateral (left) breast invasive lobular cancer, who had suspicious right breast mass on MRI examination to assess for other sites of cancer in ipsilateral and contralateral breasts. Sagittal T1-weighted contrast-enhanced image of biopsy cavity, evident as low signal air, after tissue acquisition. Enhancing lesion has undergone biopsy. Clip is obscured by air at biopsy site.

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Fig. 2F —59-year-old woman with recently diagnosed contralateral (left) breast invasive lobular cancer, who had suspicious right breast mass on MRI examination to assess for other sites of cancer in ipsilateral and contralateral breasts. Mediolateral oblique mammogram view after biopsy confirms that clip (arrow) has deployed within breast.

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Fig. 3 —53-year-old asymptomatic woman with prior right mastectomy. Sagittal fat-suppressed T1-weighted MRI of left breast shows 6 cm area of nonmass, segmental, clumped enhancement (arrows) with wash-out kinetics. MRI-guided vacuum-assisted biopsy yielded ductal carcinoma in situ (DCIS). At mastectomy, surgical histopathology yielded DCIS, cribriform, and micropapillary type, with intermediate nuclear grade and moderate necrosis and 0.2 cm infiltrating ductal carcinoma. Sentinel lymph-node biopsy performed at time of mastectomy was negative. This case, in which biopsy sampled small part of a large lesion, was the only DCIS underestimate encountered in our series of MRI-guided 9-gauge vacuum-assisted biopsy.

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Fig. 4A —54-year-old woman with history of left breast cancer with normal mammogram and no palpable lumps, in whom MRI detected spiculated right breast mass with no sonographic correlate. Sagittal fat-suppressed T1-weighted contrast-enhanced scout image from MRI-guided biopsy shows 0.9 cm mass with spiculated borders, irregular shape, and heterogeneous enhancement in right retroareolar region (arrow).

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Fig. 4B —54-year-old woman with history of left breast cancer with normal mammogram and no palpable lumps, in whom MRI detected spiculated right breast mass with no sonographic correlate. Sagittal fat-suppressed T1-weighted, contrast-enhanced image shows low-signal artifact from obturator in area of mass (arrow). Mass is less well seen due to washout of contrast and bright signal from mild hematoma. Appearance of this region did not change after biopsy.

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Fig. 4C —54-year-old woman with history of left breast cancer with normal mammogram and no palpable lumps, in whom MRI detected spiculated right breast mass with no sonographic correlate. Sagittal fat-suppressed T1-weighted, contrast-enhanced image after tissue acquisition shows biopsy cavity evident as hyperintense hematoma (arrow) deep (medial) to area of lesion. Histologic analysis yielded nodular stromal fibrosis, which was considered discordant with imaging findings.

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Fig. 4D —54-year-old woman with history of left breast cancer with normal mammogram and no palpable lumps, in whom MRI detected spiculated right breast mass with no sonographic correlate. Sagittal, T1-weighted, contrast-enhanced MRI on date of MRI-guided needle localization shows persistence of right retroareolar spiculated mass (arrow). MRI-guided needle localization yielded 0.5 cm infiltrating ductal carcinoma and ductal carcinoma in situ.

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