AJR 2003; 180:275-280
© American Roentgen Ray Society
Retrieval of Lost Microcalcifications During Stereotactic Vacuum-Assisted Core Biopsy
Paul D. Friedman1,
Linda M. Sanders,
Christine Menendez,
Lester Kalisher and
Gina Petrillo
1 All authors: Department of Radiology, Saint Barnabas Medical Center, 94 Old
Short Hills Rd., Livingston, NJ 07039.
Received February 4, 2002;
accepted after revision July 9, 2002.
Address correspondence to P. D. Friedman.
Abstract
OBJECTIVE. The purpose of our report was to describe patients in
whom calcifications in the breast that were unequivocally removed during
stereotactic core biopsy using the Mammotome device were not detected on the
initial specimen radiograph. The lost calcifications in each instance were
subsequently found when the tubing and contents of the debris canister were
strained through a nonadhering dressing and radiographed. Additional
situations in which calcifications are not seen on the initial specimen
radiograph are described and recommendations are made.
CONCLUSION. When vacuum-assisted core biopsy procedures are
performed, it is important to be aware of the possibility that calcifications
may be aspirated into the debris canister, thus compromising the accuracy of
the histopathologic diagnosis. We recommend changing the tubing and the debris
canister after each procedure and, in certain situations, sending the strained
canister contents to pathology for evaluation.
Introduction
Stereotactic core needle biopsy has become an effective and often favored
alternative to an open biopsy for nonpalpable lesions, including
microcalcifications [1]. The
11-gauge Mammotome device (Biopsys/Ethicon Endo-Surgery, Cincinnati, OH) with
vacuum assistance is particularly effective in removing larger volumes of
tissue compared with single-throw devices; in conjunction with stereotactic
digital imaging, this device provides a high degree of technical precision and
diagnostic accuracy [2,
3].
The high rate of successful calcification retrieval is directly related to
the confirmation provided by the specimen radiograph. The presence of
calcifications on the specimen radiograph ensures accurate targeting
[4]. When calcifications prompt
a biopsy, seeing calcium on a specimen radiograph is a minimum requirement to
a successful procedure and reliable diagnosis. Retrieving the tissue with the
calcifications after the biopsy and delivering it in a preserved manner to the
pathologist are of paramount importance for the success of the entire
diagnostic procedure.
In this study, we describe five patients who were referred for stereotactic
core needle biopsy because they had clusters of indeterminate
microcalcifications identified on screening mammography. In each patient,
images obtained after biopsy showed conclusively that the calcifications had
been removed from the breast, but these calcifications were not present on the
initial specimen radiograph. Subsequently, the microcalcifications were
retrieved from the debris canister and depicted on a second specimen
radiograph. To our knowledge, this series of events and mechanism of retrieval
and verification have not been previously described.
Materials and Methods
Stereotactic vacuum-assisted biopsy has been in use in our institution
since 1997. The senior breast interventionalist has been involved, through
direct performance or personal supervision of the mammography fellow, in more
than 1000 vacuum-assisted stereotactic core needle biopsies for
mammographically detected breast lesions. Cases involving microcalcifications
comprised 56% of all biopsies (699 cases). Five (0.7%) of the 699 cases
apparently had lost microcalcifications after initial biopsy.
A retrospective review was performed by the senior interventional
radiologist at our institution of 1253 patients who underwent vacuum-assisted
stereotactic biopsy from June 1997 to March 2002. The review was not presented
to the institutional review board, because it was done retrospectively. In
five of those patients who had been referred to our institution for
stereotactic biopsy, calcifications were unequivocally removed from the breast
but were not present in the initial specimen radiograph and were later
retrieved from the debris canister.
The patients were five women, 47-78 years old (median age, 64 years), who
presented with clusters of indeterminate microcalcifications that had been
identified on initial screening mammography. Previous mammograms were not
available for comparison. Magnification views were obtained in all three
projections to confirm that the lesions were true clusters and did not layer
or "teacup" on the true lateral view. In each case, stereotactic
core needle biopsy was recommended for tissue diagnosis. The stereotactic core
needle biopsy was performed on a dedicated table using digital imaging (Lorad
with Digital Spot Mammography; Lorad, Danbury, CT).
For each patient, the affected breast was placed through the opening in the
biopsy table and an appropriate approach was chosen to localize the cluster of
calcifications. Initially, a straight-on image of the calcification cluster
was obtained, then standard stereotactic images were obtained. We then
acquired approximately 10-12 tissue cores from the breast. Tissue was
vacuum-aspirated, samples were harvested, the proper tube-clamping technique
was performed during all dry taps, and a specimen radiograph of the tissue was
obtained.
In each of the five patients, a digital image acquired after biopsy
revealed no residual calcifications, and a marker clip was placed. However,
when the initial specimen radiographs failed to show the entire group of
microcalcifications, the vacuum tubing was rinsed with a saline solution and
the debris canister was emptied. For the first patient, the tubing was also
cut into pieces and radiographed. For the four subsequent patients, the tubing
was thoroughly flushed with a saline solution and the contents were placed in
the canister. The contents were then spilled onto a large nonadhering dressing
(Johnson & Johnson Medical Division of Ethicon, Arlington, TX) and imaged.
The images clearly revealed the missing calcifications in the tissue on the
nonadhering dressing. The subject tissue was then isolated, and a third
specimen radiograph was made. The tissue was subsequently placed into a
formalin container for transport to the pathology laboratory for further
analysis.
Results
The lesions in our five patients were in various quadrants of the right or
left breast; all had been designated category 4 lesions
[5] by radiologists at
referring institutions, and all were considered to be indeterminate clusters
of calcifications with a low to moderate degree of suspicion. All of the
patients underwent vacuum-assisted stereotactic core needle biopsy, and their
initial specimen radiographs showed scant or absent calcifications. In all
five cases, the tubing and debris canisters were flushed and strained onto
nonadhering dressing after the biopsies.
The initial patient, a 76-year-old woman, had coarse calcifications in the
inferior aspect of her right breast (Fig.
1A), and her initial specimen radiograph showed a fragment of a
calcification. The subsequent specimen radiographs of the nonadhering dressing
revealed additional pieces of tissue with calcifications
(Fig. 1B).
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Fig. 1A. —76-year-old woman with calcifications in inferior aspect of
right breast. Right mediolateral oblique magnification mammogram shows coarse
calcifications (arrow) in inferior aspect of breast.
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Fig. 1B. —76-year-old woman with calcifications in inferior aspect of
right breast. Magnified image of specimen radiograph from contents of debris
canister shows additional pieces of tissue with calcifications from biopsy
site.
|
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The second patient, a 78-year-old woman, had coarse irregular calcification
in the superior aspect of her right breast
(Fig. 2A); only a tiny portion
of her cluster of microcalcifications appeared on the initial specimen
radiograph. Additional pieces of tissue with calcifications were found on the
subsequent radiographs of the nonadhering dressing
(Fig. 2B).
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Fig. 2A. —78-year-old woman with cluster of microcalcifications in
superior aspect of right breast. Right mediolateral oblique magnification
mammogram shows cluster of microcalcifications (arrow) in superior
aspect of right breast.
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Fig. 2B. —78-year-old woman with cluster of microcalcifications in
superior aspect of right breast. Specimen radiograph of debris canister
contents shows substantial portion of biopsied calcifications.
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The third patient, a 47-year-old woman, had a cluster of coarse pleomorphic
calcifications in the superior aspect of the right breast
(Fig. 3A). The initial specimen
radiographs showed a portion of the calcifications biopsied
(Fig. 3B). Subsequent tissue
from the debris canister revealed additional pieces of tissue with
calcifications (Fig. 3C).
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Fig. 3A. —47-year-old woman with cluster of microcalcifications in
superior aspect of right breast. Right true lateral magnification mammogram
shows cluster of microcalcifications (arrow) in superior aspect of
right breast.
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Fig. 3C. —47-year-old woman with cluster of microcalcifications in
superior aspect of right breast. Specimen radiograph from contents of debris
canister shows additional pieces of tissue from biopsied area with
calcifications.
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The fourth patient, a 52-year-old woman, had a cluster of fine
calcifications in the superior aspect of the right breast
(Fig. 4A). The initial specimen
radiograph showed multiple tissue samples without calcifications
(Fig. 4B). Retrieved tissue
from the debris canister showed the calcifications in a single core sample
(Fig. 4C).
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Fig. 4A. —52-year-old woman with cluster of indeterminate
calcifications in superior aspect of right breast. Right mediolateral oblique
magnification mammogram shows cluster of indeterminate calcifications
(arrow) in superior aspect of right breast.
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Fig. 4C. —52-year-old woman with cluster of indeterminate
calcifications in superior aspect of right breast. Magnified image of specimen
radiograph from contents of debris canister shows calcifications to be present
in single piece of tissue.
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The fifth patient, a 54-year-old woman, had a cluster of punctate
calcifications in the upper outer aspect of her left breast. The initial
specimen radiograph showed no calcifications in the core biopsy samples. The
subsequent radiograph of specimens from the debris canister revealed all of
the targeted calcifications.
In three of these patients, the additional tissue was isolated and sent to
the pathology laboratory in specimen containers separate from those carrying
the initial core biopsy tissue. In the other two patients, the tissue
retrieved from the debris bucket was added to the initial core specimens. All
the tissue was placed in formalin containers for transport to the pathology
department.
In the second patient, pathologic examination of the initial tissue
obtained and separate evaluation of the retrieved tissue from the debris
canister resulted in the same histopathologic diagnosis of coarse
calcifications in fibrous stroma, considered to represent a portion of a
hyalinized fibroadenoma. Findings in tissue evaluated separately for the
fourth patient resulted in the histopathologic diagnosis of hyalinized
fibroadenoma in all the core samples. Tissue was also evaluated separately for
the fifth patient and showed benign breast tissue and chronic periductal
inflammation. The microcalcifications from the fifth patient were in benign
tissue; however, if they had not been retrieved, then the accuracy of the
targeting would have been seriously questioned.
In the third patient, whose initially obtained tissue and tissue retrieved
from the canister were combined, findings at pathology showed invasive mammary
carcinoma and additional foci of in situ carcinoma in all of the tissue
submitted. The pathologic diagnosis for the first patient, whose debris was
also combined with the initial tissue and sent to the pathology department,
was benign fibroadipose tissue with microcalcifications. Data and pathologic
diagnoses from the five patients are shown in
Table 1.
Discussion
These cases are presented to caution the breast interventionalist about the
possibility of losing calcifications during vacuum-assisted core biopsy.
Because of this possible outcome, it is necessary to follow the procedure for
retrieving lost tissue properly. Radiologists performing breast interventions
should anticipate the possibility of lost calcifications and should take the
proper precautions, including changing the tubing and debris canister after
each procedure.
At our institution it is routine to change tubing and the debris canister
not only after each patient, but also after each site in the same patient. If
calcifications are successfully removed from the patient but are not present
on the original specimen radiograph, the interventionalist should use a saline
solution to flush the tubing into the canister and then strain the debris
canister onto a nonadhering dressing. We have found this procedure to be
essential in salvaging the lost calcifications. In the cases presented, the
preponderance of calcifications were lost in the debris, thus raising
questions of whether the histopathologic diagnosis was representative of the
entire area biopsied.
All patients at our institution undergo digital imaging after biopsy to
evaluate for residual calcifications and to confirm removal from the breast;
some patients also undergo two-view film-screen mammography. If calcium is not
seen in the specimen radiograph or in the breast, this may indicate loss in
the debris canister or tubing, and imaging of the contents of the tubing and
the debris canister should be performed immediately. Documentation of targeted
calcifications on the specimen radiograph is a minimal requirement for a
successful procedure.
An issue of concern is that valuable tissue may be lost in the debris
bucket, even in cases of stereotactic core needle biopsy of noncalcified
lesions. The literature has emphasized that vacuum-assisted devices can remove
a substantial amount of tissue, especially when compared with other automated
devices [6]. To our knowledge,
the tissue loss that occurs when vacuum-assisted devices are used has not been
addressed in the literature. A possible reason for loss of tissue may be that
adipose tissue breaks apart easily and is readily vacuumed through suction
tubing, although this explanation is only speculation.
The risks of discordant findings after biopsy can be substantially
decreased if all of the tissue taken in stereotactic core needle biopsy is
retrieved [1]. The presence of
the calcifications on the specimen radiograph also provides proof that the
biopsy was performed in the correct location. It is possible that retrieval
can be enhanced by adding the contents of the tubing and the debris canister
to the samples sent to pathology.
Other causes for the failure to see calcifications on the initial specimen
radiograph may be present, and they should also be assessed before searching
for lost microcalcifications. Bleeding in the breast may obscure
calcifications remaining in the breast and lead to a false assumption that
calcifications should be present on the specimen radiograph. Faintness or
poorly seen amorphous calcifications in the breast may also confound the
interventionalist. These possible causes for not seeing calcifications on
specimen radiographs have been described
[6] and should be considered
before searching for microcalcifications that were presumed to be removed.
An additional cause for the failure to see calcifications on the initial
specimen radiograph is that the entities are milk of calcium, which is
particularly prone to loss and is poorly seen after biopsy because it is
dissolved in liquid and often aspirated or mixed with blood products during
the vacuum-assisted biopsy. On the basis of our experience with the
vacuum-assisted core biopsy device, we think it is important to be aware of
the possibility that in some cases calcifications may be lost, thus calling
into question the accuracy of the histopathologic diagnosis from the biopsy.
We recommend changing the tubing and debris canister after each site and are
currently evaluating whether the debris in the canister contains sufficient
diagnostic material to warrant its routine submission to pathology for
histologic diagnosis, whether or not the targeted lesion is calcified. We
further recommend obtaining radiographs of all debris in these cases in which
calcifications were not seen on the digital image after biopsy or on the
initial specimen radiograph.
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Abstract
Introduction
