C1
Finding inadequate for a diagnostic judgment; the cause shall be indicated (little or no cellularity, artifacts unsuitable equipment, etc…)
C2
Negative finding for malignant cells; sometimes specific diagnoses can be formulated (e.g., fibroadenoma)
C3
Doubt findings; the lesion is benign, but probably the presence of some atypia indicates the need for further investigation (e.g., histological biopsy)
C4
Suspicious findings; the lesion is probably malignant, the cytologic features are suggestive but not diagnostic of malignancy (e.g., lesions “borderline” or low-grade ductal carcinomas)
C5
Finding malignant; the cytologic features are diagnostic of malignancy, where possible indicate the G Nuclear and reported the presence or absence of microcalcifications
4.2.3 Indications
Despite its inherent limitations, the cytology when performed by a team of experts (radiologist, pathologist), it may still play a role, if properly placed in the diagnostic workup of breast diseases, in determining the benign or malignant lesions [10]. The choice of the lesions to be biopsied is crucial, giving careful consideration to possible alternative diagnostic tools. In particular, this technique should be preferred in lesions characterized by liquid component and/or necrosis phenomenon (complicated cysts, papillomatous lesions) [11] or localized in the particularly difficult areas (axillary, close proximity to the chest wall, the presence of breast implants adjacent).
Performing a biopsy under mammography guidance, with a stereotactic device, is reserved for lesions not visible by ultrasound, and it is, at present, less frequently used and even abandoned as, in cases of distortion of the drawing breast radial scar and microcalcifications (typical lesions best or only evident with mammography) is imperative to proceed by core biopsy or vacuum-biopsy. For the limits of FNAC related to the high percentage of inadequate (C1 2–30%), the high percentage of false negatives (5–20%), the high number of equivocal results (C3), and the inability to positive cases to evaluate the biological parameters of the tumor and to differentiate the forms in situ from those invasive, it is appropriate in most cases recourse to percutaneous biopsy. The continuation of the diagnostic with the use of percutaneous biopsy also is required in all cases of discrepancies between results of cytology and conventional imaging and in cases of equivocal (C3) to cytology, whereas the positive predictive value for carcinoma in cases C3 is 20% (in fact, some malignant lesions are more often adjustable as C3: tubular carcinoma, well-differentiated ductal carcinoma, lobular carcinoma, and ductal carcinoma, as well as some benign lesions are more often related to C3: fibrocystic, fibroadenoma, and adenosis injury) [12].
4.3 Percutaneous Biopsy
Percutaneous biopsy (PB) , performed by ultrasound or stereotactic guide needle size between 8 and 20 G, is currently the most appropriate method for the characterization of histological lesions and therefore is widely used in clinical practice to replace surgical biopsy. The small number of malignant lesions diagnosed in the final histopathological examination combined with considerable problems with surgical biopsies (high costs and stress for the patient; sometimes need to use general anesthesia, postoperative risks, such as infection, thrombosis, and embolism; scars; crowding operating rooms) have prompted the research of more cost-effective interventional techniques that are less invasive and able to get a satisfactory answer to the histological diagnosis and for planning treatment or therapeutic-surgical follow-up.
Recently, new systems have come into use that are increasingly sophisticated, easy and rapid to apply, and that allow, albeit with more complex procedure than cytology, to extract frustules of tissue sufficient for precise and complete histologic diagnosis of the lesion, which make possible adequate planning of therapeutic treatment with a consequent reduction in the number of surgical biopsies and ultimately costs. PB allows both histological and biological characterization of the lesion, thus defining aggression and appearance receptor (ER, PgR, Ki-67, C-erb B-2) [13–16].
There are several types of percutaneous biopsy depending on the type of needle that is used [2, 9, 17]:
Core Needle Biopsy or biopsy needles shot, semiautomatic type TRU-CUT, guillotine gauge between 14 and 20 G that allow you to make multiple microhistological withdrawals from the suspected area;
Vacuum Biopsy (VB) or biopsy with aspiration technique, which through gauge needles between 8 and 14 G, allow large mammary withdrawals with a single access.
No method of percutaneous biopsy is 100% accurate, even with very high sensitivity values, 95/97%, compared with 90% of percutaneous cytology [13–16]. The diagnostic capacity depends on the type of lesion (node or calcification), the diameter of the needle used (from 14G to 18G), and the amount of tissue (number of frustules) taken. Moreover, it has to be considered that 10–30% of microhistologically diagnosed carcinoma in situ is associated with foci of invasiveness discovered during the subsequent surgery. This further limits the difficulty of interpreting morphologically complex but benign diseases (atypical epithelial hyperplasia, injury sclero-elastosica or radial scar), which require for their characteristics and their possible association with foci of ADH or DCIS, excisional biopsy surgery [18–21].
Percutaneous biopsy, according to major scientific societies, is indicated in many cases, particularly in assessing [22]:
Lesions considered highly suggestive or suspicious for malignancy (BIRADS category 4 and 5), to confirm the diagnosis and guide the definitive treatment;
Lesions with multicentric distribution to facilitate the planning of the treatment;
Lesions assessed as probably benign (BIRADS category 3), only when there are valid clinical indications, in particular in the diagnosis of fibroadenoma (greater diagnostic confidence of benign lesion which relieves the patient’s stress);
Lesions undiagnosed after FNAC (C1 and C3, the discrepancy between the radiologist and pathologist);
Injuries characterized by the discrepancy between cytologic findings and clinical signs;
The use of PB also is recommended (given the paucity of material obtainable with FNAC and the high number of inadequate results) when dealing with suspicious lesions characterized by calcification and breast and radial distortions of the drawing-scar. In particular, several authors suggest using vacuum biopsy in cases of calcification to possibly take a greater quantity of material and open biopsy when dealing with the distortions of the drawing breast and the radial-scar [20, 21].
Percutaneous biopsy, generally performed as outpatient or day-hospital under (optional) local anesthesia, can be performed under ultrasound guidance, stereotactic, or magnetic resonance imaging, depending on the visibility and instrumental characteristics of the lesion.
4.3.1 Preliminary Evaluation
Before performing the biopsy, the available clinical indications must be evaluated: profiles of technical feasibility, considering the BIRADS of the target lesion, and the outcome of global imaging techniques, including mammography, echography, and mammary magnetic resonance.
It is of particular relevance that a written, informed consent is obtained and that the document contains a brief description of the procedure and includes a note that details the option of leaving a small, nonmagnetic clip (from the stereotactic guide) and the expected duration of the procedure. Moreover, it is important that the expected results and available alternatives to the biopsy are clearly stated, suggesting that this procedure has been shown to deliver a high percentage of accurate diagnoses. Finally, the risks associated with this procedure must be described, in particular the rather rare complications, typically hemorrhagic in nature, as well as short-lived neck and back discomfort due to the particular body position that must be held for several minutes during the procedure.
The general evaluation of the patient is key: in particular, the pharmacological treatment with anti-coagulant and anti-aggregant drugs must be suspended with standard methodology; and the ability of the patient to hold a supine position (for the echographic guide) or prone (for the stereotactic table) for a long enough time.
It is good practice to place a cannula on the arm that is not used for the biopsy to keep a venous access open in case complications arise during the procedure or just to satisfy standard ambulatory procedures.
4.3.2 US Breast Biopsy
When the lesion can be located through echography, this should be the method of choice to guide the intervention, because it is cheaper, more practical, simpler, and faster (3–10 min); moreover, it offers the ability to locate the needle in real-time within the lesion, as already listed for the case of the echo-guided cytological biopsy [8].
The preferred types of needle for this procedure include: Tru-cut , semiautomatic , and snap types (tip + drawer histological and shirt must be activated with two clicks imprinted on the handle by the operator) [2, 9].
The procedure is as follows: having ensured sterile conditions, the appropriate choice of needle gauge (14–20 G), and under a regime of local anesthesia, a small skin incision is performed, which facilitates the crossing of the cutaneous layer, and the needle is inserted with the tip facing the lesion. The needle path is visualized on the echography monitor (keep the probe at either 45° or parallel), and the needle is arrested when it is facing (or it has penetrated) the target lesion. We extract the guillotine (to be able to follow the progress inside the lesion), it triggers the shirt, thus cutting the carrot tissue, and pull the needle with the frustule intact inside (Fig. 4.1).
Fig. 4.1
Nodular area, hypoechoic multilobulated contours (BIRADS 3, cytology C3) (a). Extraction technique microhistology with TRU-CUT (histology: fibroadenoma) (b)
This procedure is generally repeated three to six times from different orientations, so that enough tissue might be gained from different regions of the lesion. The extracted samples must be fixed in formalin. At the end of the procedure, it is advisable to press manually onto the interested region for several minutes to minimize the risk of bleeding and hematoma formation. It is not necessary to suture the skin incision, but a sterile-strep type of medication and ice treatment can suffice. The dressing can be removed the next day.
Adopting a similar procedure, a tissue sample can be obtained with a vacuum-assisted biopsy (VAB) , employing needles with larger gauge (8 and 14 G), through which multiple samples can be obtained from a single access point. Moreover, in the case of a benign pathology, the same procedure can be adopted for the complete vacuum-assisted percutaneous removal of the mammarian lesion. It can be considered as a viable alternative to all surgeries for lesions smaller of centimeters, that did not result in “atypia” of the core-biopsy, but that are candidates for complete removal.
This procedure can be performed in the echographic room, and it is generally better accepted from patients, because of the absence of scars and because it does not requires an operating room. Also, it is generally much cheaper. Complications similar to the “open surgery” alternative are possible [23].
Once the target has been identified, a local dosage of anesthetic is delivered between the skin and the lesion and “a ventaglio” around the lesion. At that point, a small skin incision (3–4 mm) is realized and the VAB needle introduced. It is preferable to position the needle below the lesion, which is then explored in a layer-by-layer fashion. Once the removal is complete, as assessed by a real-time echography, a nonmagnetic clip can be placed.
4.3.3 Stereotactic Breast Biopsy
Stereotactic breast biopsy is an interventional radiology method for the localization, sample extraction, and, in selected cases, removal of a breast lesion that is clinically nonpalpable but has a mammographic readout. It is based on a geometrical argument, for which a pair of two-dimensional images incident at a known angle (typically 30°) can be processed to determine the localization of a given feature, such as a lesion, in a three-dimensional space (with coordinates x, y, z).
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