Interventional Breast Procedures

Interventional Breast Procedures - Needle Know-How

• Indications: Primarily for suspicious lesions (BI-RADS 4 & 5), some BI-RADS 3 (patient preference/high risk).
• Patient Preparation:
  • Informed consent.
  • Discontinue anticoagulants (Aspirin 5-7 days, Warfarin 3-5 days, check INR < 1.5).
  • Local anesthesia (Lidocaine 1-2%).
• Contraindications:
  • Absolute: Uncooperative patient, lesion inaccessible.
  • Relative: Bleeding diathesis, severe thrombocytopenia (< 50,000/μL).
• Needle Types & Guidance:
  • Fine Needle Aspiration Cytology (FNAC): 22-25G needle.
  • Core Needle Biopsy (CNB): 14-18G needle; preferred for histology.
  • Vacuum-Assisted Biopsy (VAB): 7-14G needle; larger samples.
  • Guidance: Ultrasound (most common), Stereotactic (mammography), MRI.

⭐ Key BI-RADS categories mandating biopsy: BI-RADS 4 (Suspicious) and BI-RADS 5 (Highly Suggestive of Malignancy) almost always require tissue diagnosis. BI-RADS 0 requires further imaging, and may lead to biopsy if suspicion arises on further views/modalities. BI-RADS 6 is biopsy-proven malignancy, prior to definitive therapy.

📌 Mnemonic: "Before Procedure, Check Coags" (Bleeding hx, Platelets, INR, Consent, Cease anticoagulants).

Interventional Breast Procedures - Target Acquired

• Core Principles: Obtain tissue/cells for diagnosis under image guidance.

• Pre-procedure: Informed consent, check coagulation (INR <1.5, Platelets >50,000), review medications (stop anticoagulants as per guidelines).

• Biopsy Guidance Algorithm:

• Procedure Types:

  • FNAC (Fine Needle Aspiration Cytology):
    • Needle: 22-25G.
    • Use: Cytology for cystic lesions, suspicious axillary nodes.
  • CNB (Core Needle Biopsy):
    • Needle: 14G (standard), 16G, 18G.
    • Cores: 3-5 (target ~5 for calcifications).
    • Provides histology.
  • VAB (Vacuum-Assisted Biopsy):
    • Needle: 7-11G.
    • Use: More tissue, microcalcifications, small lesions.

• Post-procedure: Ensure hemostasis, marker clip placement (common for CNB/VAB, especially if lesion is small or may be removed).

• Guidance Method Comparison:

  Feature	Ultrasound (USG) Guidance	Stereotactic Guidance (Mammo)
  Principle	Real-time imaging, any patient position	X-ray imaging, 2 views for 3D localization
  Pros	Real-time, no radiation, versatile, cheaper	Best for calcifications, non-USG visible lesions
  Cons	Operator dependent, some lesions not visible	Radiation exposure, compression discomfort, longer procedure
  Typical Lesions	Solid masses, cysts, axillary nodes	Microcalcifications, architectural distortions

⭐ Ultrasound is the most common guidance modality for core needle biopsy (CNB) due to its real-time visualization, lack of ionizing radiation, and cost-effectiveness.

Interventional Breast Procedures - Precision Probes

• Vacuum-Assisted Biopsy (VAB) / Mammotome

  • Uses vacuum to pull tissue into the needle before cutting & collecting multiple samples with a single insertion.
  • Larger tissue samples than core biopsy; can be image-guided (stereotactic, USG, MRI).
  • Therapeutic for complete removal of some benign lesions (e.g., fibroadenomas < 1.5 cm).

• Pre-operative Localization Techniques: For non-palpable lesions.

⭐ VAB is preferred for complete excision of benign lesions or extensive suspicious microcalcifications, offering both diagnostic and therapeutic benefits in a single procedure.

Interventional Breast Procedures - Smooth Recovery

• Specimen Handling:
  • Specimen radiograph: Confirms lesion retrieval & marker clip.
  • Immediate formalin fixation for pathology.
• Post-Procedure Care:
  • Firm pressure (~20 min), then compression dressing.
  • Ice packs: Reduce hematoma/pain.
  • Analgesia: Paracetamol (avoid aspirin/NSAIDs initially).
  • Restrict strenuous activity for 24-48 hrs.
  • Keep wound dry for 24 hrs.
• Common Complications:
  • Hematoma: Most frequent. Apply prolonged pressure. Large/expanding needs urgent review.
  • Pain: Usually mild; paracetamol.
  • Infection: Rare. Signs: erythema, warmth, discharge, fever.
  • Vasovagal episode: Supportive measures.

⭐ Hematoma is the most common complication following breast core biopsy.

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High‑Yield Points - ⚡ Biggest Takeaways

• Core needle biopsy (CNB) is gold standard for diagnosing suspicious breast lesions, preferred over FNAC.
• Stereotactic biopsy targets non-palpable mammographic lesions, especially microcalcifications.
• Ultrasound-guided biopsy is for sonographically visible masses, being the most common image-guided technique.
• Wire/Seed localization guides surgical excision of non-palpable lesions.
• Vacuum-assisted biopsy (VAB) yields larger samples and can be therapeutic for benign lesions.
• Most common complication: hematoma; pneumothorax is a rare risk with deep chest wall lesions.