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MR Imaging—Guided Breast Biopsy Using a Coaxial Technique with a 14-Gauge Stainless Steel Core Biopsy Needle and a Titanium Sheath

¹ Seattle Cancer Care Alliance, 825 Eastlake Ave. E., Mail Stop G4-830, P. O. Box 19023, Seattle, WA 98109.
² Department of Radiology, University of Washington Medical Center, Box 357115, 1959 N.E. Pacific St., Seattle, WA 98195-7115.

Received September 23, 2002; accepted after revision December 17, 2002.

 
Address correspondence to C. D. Lehman.

Introduction

Top Introduction Materials and Methods Results Discussion References

 
MR imaging is becoming increasingly useful in the detection, diagnosis, and treatment of breast cancer. Multiple studies have shown that MR imaging can reveal lesions that are both sonographically and mammographically occult. Because tissue diagnosis of suspicious lesions is often required, the ability to perform MR imaging—guided biopsy or wire localization is an important component of a dedicated breast MR imaging program [1–7].

Development of MR imaging—guided core needle biopsy technique has been slowed by the limited availability of MR-compatible core biopsy needles. Although nonferrous materials such as titanium are safe and produce little artifact on MR images, currently available nonferrous needles are not as effective as steel needles and are more expensive [6]. Standard 14-gauge steel core biopsy needles are considered superior in sampling to currently available core needles made of nonferrous materials; however, these needles cannot remain in the patient during scanning.

We report on a new method of MR imaging—guided biopsy that combines an MR-compatible coaxial needle to target the lesion and a standard stainless steel 14-gauge core biopsy needle to sample the lesion while the patient is outside the bore of the magnet.

Materials and Methods

Top Introduction Materials and Methods Results Discussion References

 
MR imaging—guided biopsy is performed when a lesion with suspicious characteristics is identified on MR imaging and is occult on mammography, sonography, and physical examination. Written informed consent is obtained and IV access established. A dedicated breast coil and biopsy guidance device (MRI Devices, Waukesha, WI), described previously [8], is used with an LX 1.5-T MR scanner (General Electric Medical Systems, Milwaukee, WI) (Fig. 1).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —Photograph of breast biopsy device (MRI Devices, Waukesha, WI), with guide adjustable along anteroposterior and superoinferior axes in millimeter increments. Needle guide adjustable along mediolateral axis is also in place.

The patient is positioned prone with the affected breast in the biopsy guidance device. Moderate compression is applied to stabilize the breast position. A fiducial marker is placed on the skin through the positioning device in the region of the lesion to be sampled. The fiducial marker is a hollow plastic tube filled with a 1:100 gadolinium—normal saline dilution.

After obtaining localizing sequences, we acquire sagittal three-dimensional gradient-echo rotating delivery of excitation off-resonance images of the entire breast (TR/TE, 20/5; flip angle, 45°; field of view, 20 cm; slice thickness, 1.2 mm; matrix, 256 x 128; number of excitations, 1) and anteroposterior frequency sequences before and after contrast administration. We review the images on the monitor and record the locations in millimeters of the fiducial marker and lesion along the anteroposterior, superoinferior, and mediolateral axes on a biopsy-positioning flow sheet (Fig. 2).

View larger version (18K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —Biopsy-positioning flow sheet for calculating adjustments necessary for precisely targeting sagittal biopsy of breast from lateral approach. Sixty millimeters accounts for portion of sheath outside of body. x-axis = right—left (R/L, mediolateral), y-axis = anteroposterior (A/P), z-axis = superoinferior (S/I).

The flow sheet is designed to facilitate recording the locations of the fiducial marker and lesion in the x-, y-, and z- axes. The differences are calculated and the needle guide is adjusted appropriately along the superoinferior (z) and anteroposterior (y) axes. The mediolateral (x) axis coincides with the depth of the lesion from the incision site. Sixty millimeters is added to the skin-tolesion depth to account for the space from the hub of the needle guide to the skin.

The MR imaging table is moved out of the bore of the magnet, and the needle guide is adjusted to the nearest millimeter. The fiducial marker is removed, the patient's skin is sterilized, and local anesthetic is injected (lidocaine mixed with bicarbonate, 1:10 solution). A sterile 12-gauge titanium coaxial needle is inserted to the calculated depth utilizing the centimeter markers on the shaft of the needle. The coaxial needle consists of an outer titanium cannula and an inner titanium stylet. A small skin incision is made before inserting the needle. Once the coaxial needle is placed, the inner stylet is removed, and, with the cannula in place, the table is returned to the bore of the magnet for imaging to confirm the cannula position.

A limited axial sequence is performed through the region of the cannula and lesion (T1-weighted fast spin-echo with fat-suppression sequence of 4-mm axial slices). The tip of the cannula and the lesion are identified on the monitor, and corrections along the x-, y-, and z-axes are calculated if necessary. Placing the tip of the sheath opening 1 cm proximal to the lesion center is ideal. This accounts for the 20-mm throw of the needle and the "dead space" of the needle tip distal to the sampling chamber. The patient is rolled out of the bore of the magnet and adjustments are made if needed. If the cannula is repositioned, a limited axial T1-weighted fast spin-echo sequence is repeated to confirm the position. Once correct placement of the cannula is confirmed, the table is rolled out of the bore of the magnet, and multiple core samples of the lesion are obtained using a standard stainless steel 14-gauge disposable core needle biopsy system (Monopty biopsy instrument, Bard, Covington, GA) through the titanium cannula.

After sampling, a site marker can be placed through the cannula. Many site markers can be used. Currently, we use the Inrad ultraclip tissue marker (Kentwood, MI). The marker can then be used to localize the biopsy area with standard mammography, thus avoiding the need for MR imaging—guided localization if the core biopsy reveals cancer, atypia, or a discordant result. A final sagittal sequence through the region of the biopsy is performed to confirm the location of sampling and successful placement of the marker.

At completion of the biopsy, the biopsy needle and coaxial cannula are removed, hemostasis achieved, and the wound dressed.

Results

Top Introduction Materials and Methods Results Discussion References

 
Initial experience with five consecutive patients has shown the method described to be effective and safe. Four masses and one area of regional enhancement were biopsied. Adjustments after the first needle placement were made in one patient. In this initial series, additional gadolinium injection was not necessary, although it can be performed as needed in small lesions that show washout of contrast material. The masses ranged in size from 7 to 13 mm (mean, 9.5 mm; SD, 2.6 mm). The average procedure time (from initial targeting sequence to final postbiopsy sequence) was 47 min (SD, 16 min). Approximately six to 10 samples were obtained from each patient.

All biopsies resulted in tissue retrieval. Two of five biopsy specimens, including the smallest lesion sampled, were confirmed as infiltrating carcinoma (Figs. 3A, 3B, 3C, 3D). One was ductal, one was lobular, one revealed atypical ductal hyperplasia, and two were benign. There were no complications during or after the procedures. Surgical followup in three patients confirmed the core biopsy histology (two malignant, one benign). Follow-up MR imaging documented the decreased size of the second benign mass 6 months after the core needle biopsy, indicating benign fibrosis. The patient with documented atypical ductal hyperplasia at core needle biopsy declined recommended surgical excision.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —Selected images from single MR imaging—guided breast biopsy of 60-year-old woman with infiltrating ductal carcinoma. Sagittal MR image shows fiducial marker.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —Selected images from single MR imaging—guided breast biopsy of 60-year-old woman with infiltrating ductal carcinoma. Contrast-enhanced sagittal MR image shows enhancing 5-mm lesion.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —Selected images from single MR imaging—guided breast biopsy of 60-year-old woman with infiltrating ductal carcinoma. Axial MR image shows titanium coaxial needle positioned just proximal to lesion.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —Selected images from single MR imaging—guided breast biopsy of 60-year-old woman with infiltrating ductal carcinoma. Postbiopsy sagittal MR image reveals biopsy defect and site marker artifact near lesion. Histology confirmed infiltrating ductal carcinoma.

Discussion

Top Introduction Materials and Methods Results Discussion References

 
The combination of immobilization of the breast with compression and the use of a titanium coaxial needle with the biopsy targeting device allow consistent and precise spatial localization of a lesion. In addition, the titanium coaxial needle produces minimal interference during imaging, so the lesion remains visible even at its tip. The stainless steel biopsy gun is a more reliable and less expensive sampling device.

The physician and technologist should use caution when practicing this method. We use a disposable steel core biopsy needle in which the housing mechanism is plastic. During the procedure, we keep the needle on a plastic cart in the corner of the room, well outside the 5-G line. We performed safety checks and tests with our specific tools and room before initiating this method with patients.

This technique of using an MR-compatible coaxial needle for targeting and a stainless steel 14-gauge core needle for tissue sampling provides a safe and effective method for breast biopsy under MR imaging guidance with a 1.5-T closed system magnet. The advantages of this new method include use of a more effective and more widely available needle for more effective sampling and lower procedure cost. Larger studies with long-term follow-up are required for more definitive evaluation of this new technique.

References

Top Introduction Materials and Methods Results Discussion References

 

1. Daniel BL, Birdwell RL, Butts K, et al. Freehand MRI-guided large-gauge core needle biopsy: a new minimally invasive technique for diagnosis of enhancing breast lesions. J Magn Reson Imaging 2001;13:896 –902[Medline]
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6. Kuhl CK, Morakkabati N, Leutner CC, Schmiedel A, Wardelmann E, Schild HH. MR imaging-guided large-core (14-gauge) needle biopsy of small lesions visible at breast MR imaging alone. Radiology2001; 220:31 –39[Abstract/Free Full Text]
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