Abstract
The advent of stereotactic and ultrasound (US) guidance combined with the development of automatic, easy-to-use core-needle biopsy (CNB) devices marked the beginning of a new era in the field of imaging-guided percutaneous breast biopsy. The various automatic and manual devices available for CNB and their mechanisms are described. The complete standard technique of the CNB procedure is detailed from the preparation of the patient to the processing of the cores. A large section is devoted to the documentation of the procedure. Artifacts, errors, and pitfalls in the performance of US-guided CNB are discussed along with their solutions. Finally, an original technique of US-guided CNB of the skin is presented.
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Videoclip shows the mechanism of action of the disposable Achieve biopsy device (Becton Dickinson) in full automatic mode. The device is cocked: first, the stylet and then the cannula are retracted, and their respective springs are compressed and held in place. By pressing the trigger, both the stylet and cannula are propelled quasi-simultaneously, the cannula following the stylet within a fraction of a second. This is the basic action mechanism of all automatic CNB devices using Tru-Cut needles (MOV 649 kb)
Videoclip shows the activation of the disposable automatic Maxcore (Bard) biopsy device (here with a 14-gauge, 10-cm-long Tru-Cut needle). The device is held in the cocked position with the right hand (by a right-handed operator). The thumb is placed on the trigger, ready to press it. Note that there is no safety lock on this device. When the needle is in the correct position (i.e., in contact with the target and entirely visualized in the transducer’s field of view), the operator simply presses on the trigger to activate the internal springs on the device; in a fraction of a second, the inner stylet is propelled, followed immediately by the cutting cannula (MOV 6247 kb)
Videoclip shows the delayed action of the Achieve programmable semi-automatic biopsy device. By pressing on the “delayed” trigger (D), the operator “fires” the stylet. After verifying the correct position of the notch of the stylet in the target, the operator can press the “automatic” trigger (A) to release the cutting cannula and actually perform the CNB (MP4 2218 kb)
Delayed action of the Achieve programmable semi-automatic biopsy device. The stylet is propelled first. The characteristic notch of the stylet is easily identified (arrows), and its position is adjusted to “catch” the targeted mass. Then the cutting cannula is fired to cut the core and complete the biopsy. Lastly, the probe is swiveled 90° to confirm that the needle has traversed the target (MP4 14174 kb)
CNB performed with the zero-throw technique. The videoclip shows first the Tru-Cut needle, which has been inserted through a small nearly isoechoic mass. Then the cutting cannula is manually retracted exposing the notch in the Tru-Cut needle’s stylet. After the probe has been turned 90° to confirm the correct placement of the needle in the center of the mass, the probe is placed back longitudinally to show the correct position of the notch in relation to the target. Finally, the cutting cannula is fired to cut the core (see also Fig. 12.8). Note that the tip of the CNB needle remains stationary during the biopsy (MP4 19059 kb)
CNB with a manual (semi-automatic) 16-gauge biopsy device (Temno Evolution). The videoclip shows the manual insertion of the stylet into the tumor until the notch is seen in the proper position to activate the cutting cannula (see also Fig. 12.10) (MP4 10867 kb)
Videoclip showing the mechanism of action of the Cassi biopsy device in a phantom consisting of a pimento-containing olive placed in a turkey. The small central guiding needle has been placed through the olive. As the pressurized CO2 from the cartridge circulates through the needle, it rapidly freezes and immobilizes the olive (“stick-freeze”) before the larger (10-gauge) cutting cannula is actually propelled forward to cut the core. Note that as the freezing process takes place (in a few seconds), the shadow distal to the needle increases (see also Fig. 12.16) (MP4 16293 kb)
Local anesthetization performed under US guidance prior to CNB of a small carcinoma. The xylocaine solution is injected slowly as the 21-gauge hypodermic needle advances toward the targeted lesion along the planned CNB needle pathway. The solution can be seen to dissect the soft tissues, separating lobules of fat. After the solution has been deposited at the contact with the lesion, it continues to be delivered while the needle is withdrawn. Eventually, before withdrawing the needle completely, 1 ml of xylocaine solution is injected immediately under the skin (not shown) (MP4 22099 kb)
Demonstration of the comet-tail artifact (tip artifact) that is the signature of the distal extremity of the Tru-Cut needle during the CNB of a fibroadenoma. The echogenic needle is slightly moved laterally side to side (see also Fig. 12.36) so that it comes in and out of plane until the tip artifact appears on the screen (arrow), indicating that the entire needle, including its tip, is perfectly aligned with the scan plane. Firing the biopsy gun at this time guarantees a successful hit (MP4 13025 kb)
Videoclip shows the lateral side-to-side sweeping motion of the Tru-Cut needle, which comes in and out of view until it is aligned with the small 5-mm cancer and the reverberations from its tip (tip artifact) are visible. The biopsy gun can then be fired (see also Fig. 12.39) (MP4 5912 kb)
CNB of a 0.8-cm carcinoma. The lateral side-to-side sweeping motion of the Tru-Cut needle makes it come in and out of sight. Before the biopsy gun can be fired, the shaft of the needle must be well seen, but more importantly, its tip must be identified via the characteristic tip artifact (see also Fig. 12.41) (MP4 10779 kb)
Videoclip shows the technique of lateral side-to-side gentle sweeping of the needle to adjust the alignment of the Tru-Cut needle with a small target (arrows) until the tip artifact is well demonstrated, confirming the perfect positioning of the cutting needle prior to taking the biopsy (see also Fig. 12.42) (MP4 10697 kb)
CNB of a “complex” calcified fibroadenoma. The videoclip shows the Tru-Cut needle “teasing” the lesion and mobilizing it easily, which is a clue to its benign nature (MP4 10722 kb)
A 26-year-old woman with a recently discovered smoothly marginated, palpable breast mass. The videoclip shows how to use the Tru-Cut needle to test the elasticity or firmness of the mass before firing the device and taking the biopsy. In this case, the mass was extremely elastic and deformable, a clue to its benign nature. Pathological examination revealed stromal fibrosis and pseudoangiomatous stromal hyperplasia (PASH) (see also Fig. 12.45) (MP4 11168 kb)
Digital videoclip documenting a successful pass of a US-guided CNB of a 7-mm carcinoma. The needle is aligned with the target, the CNB device is fired, and the needle is seen traversing the target. The probe is then rotated 90° and the echogenic cross section of the needle is documented in the center of the small tumor (MP4 8442 kb)
Complete documentation of one CNB pass in a small carcinoma with a continuous videoclip, from the pre-firing adjustment of the Tru-Cut needle to the post-firing 90° view (MP4 17183 kb)
Digital copy of the original S-VHS footage of the uninterrupted video recording of the CNB of a 1-cm high-grade invasive ductal carcinoma at 6 o’clock position in the right breast. The continuous recording starts with US-guided local anesthetization along the planned pathway of the CNB needle, which takes about 1 minute. Then the three successful passes through the target with the 18-gauge Tru-Cut needle of the automatic Maxcore CNB device are documented in sequence (MP4 102766 kb)
Videoclip shows a trace of echogenic air (arrow) moving back and forth in the track of a previous pass of CNB of a minute benign lesion (MP4 17582 kb)
Videoclip shows the motion of a tiny amount of blood that shifts direction inside the horizontal track of the Tru-Cut needle in the center of the tumor as the transducer is rocked laterally over the tumor (MP4 8513 kb)
After the firing of the CNB needle and swiveling the probe 90°, there are two bright echoes in the target mass: one is the trace of the previous pass and the central one which represents the cross section of the needle, which is confirmed by the motion of the echo when the needle is rotated clockwise and counterclockwise (MP4 7834 kb)
Recovery of cores from the Tru-Cut needle of an automatic CNB device (Maxcore) on a non-adherent Telfa gauze. The cutting cannula is retracted manually to expose the core, which is seated in the notch of the stylet. A gentle sweeping motion of the needle extremity onto the Telfa gauze is sufficient to unload the core from the stylet (MOV 23598 kb)
Coaxial technique of CNB with an introducer. The operator slides the CNB needle through the introducer to bring it in contact with the target and verifies its proper alignment prior to taking the first biopsy (MOV 25868 kb)
Coaxial technique of CNB with an introducer. After the CNB device has been removed and the first core recovered, it is recocked and introduced again through the introducer, which stays in place during the entire biopsy (MOV 10978 kb)
Coaxial technique of CNB with an introducer. After the CNB, advantage is taken of the presence of the introducer to insert the needle used to deploy the biopsy marker in the target lesion, if necessary (MOV 56106 kb)
Patient with a palpable invasive lobular carcinoma, which measured 2.5 cm at pathological examination. A small hypoechoic lesion was identified initially (see Figs. 12.59a, b). Compression maneuvers allow the breast imager to better discern the ill-defined margins of the tumor, which shows mixed echogenicity. In this case, aiming the CNB only at one of the small hypoechoic components may fail to obtain diagnostic malignant material (MOV 2884 kb)
US-guided CNB of suspicious microcalcifications (see Fig. 12.73). PDUS examination of the palpable mass shows the large cluster of suspicious microcalcifications that was seen on mammograms (vertical arrow) and an adjacent irregular hypoechoic and hypervascular mass (horizontal arrow) that was biopsied along with the microcalcifications. Pathological examination confirmed a high-grade invasive ductal component and DCIS (MP4 17369 kb)
Area of distortion detected on mammograms in a 38- year-old woman. An inadequate US examination performed at another facility with improper settings described a 2.5-cm malignant-appearing mass, for which a US-guided CNB was recommended (see also Fig. 12.80b). Videoclip shows an area of fibrocystic changes with numerous cysts and an area of “pulling” (arrow) that correlates with the area of distortion on the mammograms and is suggestive of a radial scar. In any case there is no discrete suspicious mass. A stereotactically guided VAB confirmed the diagnosis of radial scar (MP4 6806 kb)
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Fornage, B.D. (2020). Core-Needle Biopsy. In: Interventional Ultrasound of the Breast. Springer, Cham. https://doi.org/10.1007/978-3-030-20829-5_12
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DOI: https://doi.org/10.1007/978-3-030-20829-5_12
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