Valerie

P. Jackson,

#{149} Handel

MD

E. Reynolds,

MD

Stereotaxic Needle-Core and Fine-Needle Aspiration Evaluation ofNonpalpable use of screening mammography has increased in the United States, so has the desire to reduce the cost, anxiety, and morbidity associated with surgical biopsy of nonpalpable breast lesions. Fine-needle aspiration biopsy (FNAB) performed with mammographic, stereotaxic, or sonographic guidance has been investigated as an alternative to surgical biopsy. A number of problems, however, have been associated with FNAB. They include specimen insufficiency and the lack of wideS

spread

expertise

in breast

cytopathol-

ogy in the

United States. In recent months, needle-core biopsy has received a great deal of attention as an alternative to FNAB for the evalualion of nonpalpable breast lesions. It seems that obtaining a large core of tissue for histologic examination should reduce the sampling and expertise problems

of cytologic

provide

a better

evaluation

alternative In two

and

to surgery

for many women. studies comparing core biopsy with FNAB of palpable breast masses, however, FNAB was shown to be superior (1,2). Lovin et al (3) and Parker et a! (4,5) have reported encouraging results for stereotaxically

localized

core biopsy

of nonpalpable

breast lesions, but they did not compare it with FNAB. In this issue of Radiology, Dr Dowlatshahi and his coauthors present their data regarding needle-core biopsy of nonpalpable breast lesions (6). This

group

is to be

ing the difficult study comparing

Index terms: biopsy, 00.31,

00.125 00.32

Radiology

I

From

but

for

desperately FNAB, core

Biopsies, #{149} Breast #{149} Editorials

1991;

the

commended

technology neoplasms,

complet-

needed biopsy,

Breast,

#{149}

diagnosis,

181:633-634

Department

of Radiology,

Indiana

School of Medicine, Wishard Memorial Hospital, 1001 W 10th St. Indianapolis, IN University

46202. Received and accepted September 20, 1991. Supported in part by grant ROl CA48004 from the National Cancer Institute, National Institutes of Health. Address reprint requests to V.P.J. C RSNA, 1991 See also the article by Dowlatshahi et at (pp 745-750) in this issue.

and

surgical

Biopsy Cytologic Breast Lesions’

biopsy

in all of their pain their article,

tients. As demonstrated number of points should before rated

core biopsy into American

be considered

studies the (3-5),

suggest that core problems of cytoDowlatshahi et al

have shown that there are important limitations to the technique (6). Their results suggest that a 20-gauge core biopsy is far from perfect, despite multiple passes and the use of the better Monopty (distributed by Bard Urological, Covington, Ga; manufactured by Radiplast, Uppsala, Sweden), rather than Biopty (Bard Urological), device.

While

the results

of Parker

et al appear

to be better (5), their technique of multiple passes with a 14-gauge needle can hardly be considered atraumatic and

would

be somewhere

between

the

be accurate,

and

needle

placement

multiple

passes

must

are

to achieve optimal results. As shown by Dowlatshahi et al, sampling error and specimen damage can occur with core biopsy (6). When one removes relatively large pieces or the entirety of a very small lesion with a core biopsy needle, the lesion may no longer be radiographically visible for subsequent surgical biopsy. If the neenecessary

is widely incorpomammography

practices. While earlier biopsy eliminates logic evaluation

experienced, a

surgical

dle biopsy

specimen

damaged,

or interpreted

is inadequate, as “suspicious”

but not definitely malignant, management becomes a major dilemma. While this

unfortunate

ported

event

in the series

has

not

of Parker

been

re-

et al (4,5)

or Dowlatshahi et al (6), it has occurred in six of 70 cases in a study performed by Dronkers (7). While all authors have emphasized the need for multiple passes with the core biopsy needle (3-6), the optimal

biopsy and FNAB in comfort and invasiveness for the patient. Despite the limitations of the technique, the smaller gauge of the core biopsy needle may be a more acceptable alternative at those facilities in which the upright “add-on”

number

stereotaxic

it would be helpful to determine the minimal number of passes necessary for acceptable results. This could easily be done by sequentially numbering the individual specimens obtained and evaluating the number of samples required for a large

devices

rather than are used.

Specimen issue

for any

number taming These erator, needle number method rience,

the

for localization,

prone

adequacy type

of factors

stereotaxic

table,

is an important

of needle

biopsy.

are involved

A

in ob-

good specimens for FNAB. include the experience of the opnature of the lesion, accuracy of placement, aspiration technique, of samples obtained, and of slide preparation. With expethe potential problems can be

minimized,

but not totally

eliminated.

In the ideal situation, multiple passes are made and the slides are prepared by the cytopathologist, who is present at the biopsy procedure. By using quick staining techniques, the cytopathologist can assess for specimen adequacy during the procedure and request additional specimens, if necessary. The presence of the cytopathologist adds cost and time to the FNAB procedure, how-

ever, and is tice settings. problems of need for an Nevertheless,

not feasible in many pracCore biopsy eliminates the slide preparation and the on-site cytopathologist. the operator must still be

of

passes

mined.

Parker

samples

(4,5),

performed

cause

remains

while

two

this

deter-

four

Dowlatshahi

or three

method

more invasive and potential morbidity,

number

to be

et al obtained passes

or five et al

(6).

of needle

biopsy

associated

with

Be-

is

more

of cases.

Stereotaxic technology is now several years old, but there continue to be many technical problems associated with the units, particularly the upright add-on devices. The use of automatic core biopsy needles adds further difficulty. These large needles have a long firing range (1.7 or 2.3 cm), and the firing mechanism is powerful. The stereotaxic units must be modified, or careful calculations must be made, to ensure that the needle does not impinge on the cassette holder.

An important advantage of core is the ability of the pathologist

opsy

differentiate

(DCIS)

ductal

from

carcinoma

an invasive

bito

in situ

carcinoma.

Most surgeons and oncologists that the distinction is important the management of these two lesions may differ. With current

believe because types of tech633

nology,

it is not possible to distinguish these lesions with FNAB, and

between

sampling more Such

appear

to be

likely for an intraductal sampling error, however,

error

would

tumor. may

also

occur with needle-core biopsy, and an invasive carcinoma with an extensive intraductal

component

may

be misdiag-

nosed. Careful mammographic correlation may alert one to the possibility of the presence of DCIS or an extensive intraductal component, but histologic evaluation diagnosis.

is necessary

for definitive

or surgeon

will not believe

Their results are, frankly, discouraging. They advocate the use of both FNAB and core biopsy for all “low-suspicion” lesions. Is this really necessary? Could

for the

and

Again,

must

for multiple

these

patients.

would expect accurate diagnosis to be more likely when a larger piece of tissue is obtained. Dowlatshahi et al postulate

Will the use of needle biopsy nate the need for short-interval

that

cion lesions? to date (3-6),

of the aspirating

needle

low-up

“found at surgical biopsy, was missed at needle biopsy as a result of suboptimal needle localization” (5). Nine cancers were missed with both FNAB and core biopsy in the series of Dowlatshahi et al

needle

importance

is the

ef-

fect of needle biopsy results on patient care. This varies from practice to praclice. If the patient, referring physician,

634

#{149} Radiology

2.

these

pa-

biopsy needle

elimifol-

From the published series it is difficult to determine

interval only tient.

Both

and

cost

core

biopsy

of additional ters,

however,

the utility

research type

ous practice settings. purchasing equipment FNAB or core biopsy,

7.

8.

of deal

cen-

to determine

of biopsy

KW,

in vari-

or bi-

needle

Alagaratnarn

U.

role of fine needle

as-

cytology and Tru-cut needle bithe management of breast masses. Z I Surg 1987; 57:615-620. MM, Goldberg IM, Schick P, NiePilch YH. Aspiration cytology is to Tru-Cut needle biopsy in estabthe diagnosis of clinically suspicious

masses.

Ann Surg

1982;

Lovin JD, Parker SH, Jobe Hopper KD. Stereotactic

core biopsy:

196:122-126.

WE, Leuthke percutaneous

technical

JM,

adaptation

and initial experience. Breast Dis 1990; 3:135-143. Parker SH, Lovin JD, Jobe WE, et al. Stereotactic breast biopsy with a biopsy gun. Radiology 1990; 176:741-747. Parker SH, Lovin JD,Jobe WE, Burke BJ, Hopper KD, Yakes WF. Nonpalpable breast lesions: stereotactic automated large-core biopsies. Radiology 1991; 180: Dowlatshahi

K, Yaremko

Jokich

Nonpalpable

PM.

L, Kluskens LF, breast lesions:

Dronkers DJ. Stereotactic histological biopsy of nonpalpable breast lesions. Radiology (in press). Helvie MA, Pennes DR. Rebner M, Adler DD. Mammographic follow-up of low-

suspicion

9,

are prom-

at multiple

is necessary

of each

piration opsy in Aust N Shabot berg R,

agnostic

pa-

ising techniques for the evaluation nonpalpable breast lesions. A great

PS, Yan

of

findings of stereotaxic needle-core biopsy and fine-needle aspiration cytology. Radiology 1991; 181:745-750.

the

to the

be optimized

addition

403-407. 6.

as short-

mammography,

is increased

FNAB

5.

If one per-

as well

follow-up effect

4.

strategy for “probably and calcifications (8-10).

is necessary.

Cheung

breast

for low-suspi-

biopsy

indeed the

U

lishing

in

In the large prospective study of Sickles, only 0.5% of the cases were subsequently found to be malignant (10). Thus, one must question whether any forms

by

superior

3.

whether a significant number of the lesions undergoing needle biopsy are those that most mammographers would merely follow mammographically. Follow-up has been shown to be an effec-

tive management benign” masses

Of paramount

discuss

The complementary

the

techniques

mammography

and clinical correlation are important. For lesions that are mammographically suspicious for malignancy, a negative finding at core biopsy or FNAB should not preclude surgical biopsy. In the latest series of Parker et al, one cancer

(6). Thus, the results of any type of needle biopsy must be used intelligently in planning case management.

biopsy

would

breast

question

need

the motion

carefully

References

“high-suspicion”

one

care

opsy.

needles? Dowlatshahi et al also advocate FNAB before surgical biopsy of all

diagnosis of masses (6). Microcalcificalions frequently herald DCIS, and one

“breaks down the supportive structures and frees the cells which are aspirated into the needle” (6). Whether this is true remains to be proved. Regardless of the type of needle biopsy performed, careful mammographic

that

1.

the need for FNAB be eliminated or reduced by the use of larger core-biopsy

lesions.

superior

should

improved

while

was

pher

other step to an already expensive workup. Dowlatshahi et al compared the cost of FNAB and core biopsy with surgical biopsy at their institution (6).

“intermediate-”

biopsy

of

tient-care issues with all the physicians involved in the treatment of breast disease at his or her institution to ensure

It is surprising and interesting that, in the study of Dowlatshahi et al, cytologic evaluation was better than core biopsy for the diagnosis of microcalcifications, core

the result

the needle biopsy, and surgical biopsy is still performed for many or most cases, then the needle biopsy is not affecting management and is merely adding an-

10.

lesions: yield.

compliance

Radiology

1991;

rate and di-#{149} 178:155-.

158. Ikeda DM, Bondeson L, Helvie MA, Rebner M, Adler DD. Evaluation of nonpalpable breast nodules: 4-month mammographic follow-up versus x-ray-guided fine needle aspiration. Breast Dis 1991; 4:205-218. Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology 1991; 179:463-468.

Before actually to perform the mammogra-

December

1991