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Surgical Technique
Needle-localised biopsy of impalpable breast lesions:
A novel adjunct to surgical technique and specimen
mammography
C. Power D. Kavanagh A. D. K. Hill A. O’Doherty1 N. O’Higgins E. McDermott
Surgical Professorial Unit, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
1Department of Radiology, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland
Correspondence to: Mr Colm Power, Vascular Laboratory, Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland Email: cjppower@yahoo.com
Keywords: Cancer, specimen mammography, surgical biopsy
Surg J R Coll Surg Edinb Irel., 1 December 2004, 343-345
Successful screening programmes have resulted in the more frequent detection of early impalpable breast tumours. Effective surgical management of impalpable lesions demands a precise approach to excision which is currently aided by radiologically guided needle-localisation of the lesion prior to operative removal. The surgical specimen procured is most commonly evaluated for tumour presence by specimen mammography intra-operatively or by histological analysis. The latter is more accurate but requires lengthy laboratory processing, which may result in re-operation if the primary excision is inadequate. Although advocated as the standard of care, specimen mammography remains an imperfect technique. In this article we describe a piece of surgical apparatus which attempts to address some of the concerns associated with specimen mammography. It is an inexpensive compression device which reduces operative time, avoids portable fluoroscopy, increased radiation and the necessity for specialised equipment
The advent of successful breast screening programmes has resulted in a higher rate of abnormal mammographic findings. This translates into the more frequent detection of early, impalpable breast cancers. Currently, there are several options available by which breast tissue can be obtained for the pathologic evaluation of non-palpable mammographic lesions. However, needlelocalised breast biopsy (NLBB) remains the most widely used diagnostic method after stereotactic core-biopsy.1 If NLBB meets the oncologic criteria of clear margins in patients with small cancers it can also serve as the definitive local procedure for those wishing breast conservation. This technique generally has a very low failure rate, although, occasionally, residual tumour rates of 55-64% have been reported.2-4
Specimen mammography (SM) is commonly practiced as an adjunct to mammographically-guided needle-localised breast biopsy. The American College of Radiology states that SM is the “standard of care” for NLBB.5 They advocate SM as it allows surgeons to assess the adequacy of excision and reduces the number of metachronous re-excisions that are required to achieve clear margins.
Despite this, some authors are quick to draw attention to the fact that SM is not without problems. They claim that SM prolongs surgical procedures and incurs significant expense.6 Incorrect results can additionally lead to the excision of unnecessary tissue, delay in the recognition of a malignant lesion and a false sense of security that the abnormality has been appropriately excised.7
In this article we describe the use of a simple device which attempts to minimise these legitimate concerns.
Mammographically-guided wire-localised breast biopsy is a two-stage procedure. A standard hooked wire is placed to identify the lesion by the radiologist in the mammography suite. This single wire can occasionally be complemented by a second wire sited in close proximity to the first to better delineate the position of the mammographic abnormality. Instructions from the radiologist indicate the exact location of the lesion in centimetres from skin and in relation to the needle tip(s). This information enables the surgeon to excise the abnormality accurately (second stage) and with subsequent SM, confirm the presence of the lesion within the resected tissue specimen. We routinely tag the biopsy specimen with radio-opaque metal clips to aid in orientation (one clip = medial margin, two clips = anterior margin, three clips = superior margin). We have subsequently developed a device which facilitates specimen mammography by compression.
The compression tool is constructed from two transparent, radiolucent perspex plates (10cm x 10cm). At the four corners of the lowermost plate are fixed four immobile metal rods. Similarly located apertures in the uppermost plate allow the latter slide up and down along the rods. Four tightly coiled metal springs, spiralled around the four metal rods, are capable of maintaining both plates in close adherence. Any tissue specimen placed between these is effectively compressed, thereby increasing the likelihood of identifying subtle calcifications or other abnormalities (Figures 1a and 1b). Our experience, to date with this tool has reduced the necessity for magnification and similarly obviates the requirement for multiple views of the specimen. In conjunction with metal clips, the compression apparatus facilitates accurate identification of the mammographic abnormality and margin assessment (Figure 2).
Figure 1a: A “bird’s-eye” view of the compression apparatus demonstrating central placement of the biopsy specimen.
Figure 1b: A side view of the device demonstrating effective compression of the tissue specimen between both plates, forced into close adherence by the spiralled coils of spring.
Figure 2: Specimen mammogram facilitated by the compression device. The lesion is easily identified, the metal clips delineate the margins (see text) and complete excision is clearly demonstrated.
The two most frequently employed methods of predicting the presence of residual tumour in the breast include assessment of biopsy specimen margins for tumour and the use of SM. Breast cancer is associated with calcifications in 40% of cases.8,9 Thirty to fifty per cent of non-palpable carcinomas, 90% of non-palpable ductal carcinoma in situ and 70% of micro-carcinomas are visible on the basis of micro-calcifications alone.
10,11 For these reasons, SM is strongly recommended and widely performed after NLBB. Of these two techniques, assessment of surgical margin status is cited as the gold standard for determining the adequacy of resection. However, neither method is completely reliable. For example, Frazier et al (1989) found residual tumour in 26% of patients with biopsy margins that were free of tumour, and similar findings (33%) have been reported by other authors.12,13
Aitken et al (1990) studied 46 women with two-view intra-operative SM and correlated the SM findings with margin-involvement of the biopsy.14 The disappointing results reported (correct predictive value evident in one of each nine cases) may be attributable to the fact that 11% of the SM’s did not show the tumour and an additional 37% demonstrated the lesion on only one of two views. Operative technique could conceivably have been a factor, however, as a more recent report indicates that if needle-guided biopsy is performed well, only 1.8% of patients benefit from SM. The latter authors found that most localisation breast biopsies completely excise suspicious mammographic abnormalities on the first attempt.6
These disparate results indicate that there is a significant “middle ground” where improved methodology to optimise needleguided breast biopsy may be required. It is in these circumstances that the tool described in this article may provide additional accuracy and greater confidence in the specimen procured. Our device differs from other methods of improving the yield from NLBB which require the use of portable fluoroscopy and increased operating time, are coupled with increased radiation or the necessity for highly specialised equipment.15-17 This piece of apparatus is easily constructed from relatively inexpensive materials. As the biopsy specimen can be placed between the plates after excision it does not need to be sterilised or even brought into the operating suite.
This report has not addressed sensitivity or specificity, as these parameters are not easily measured when assessing a device such as this. Its utility is subjective in that it requires that a surgeon be competent in his/her primary resection technique. In concert with many Breast Units we employ a Faxitron Specimen Radiography System MX-20 (Faxitron X-Ray Corporation, Illinois, USA) to image surgical specimens in the theatre complex. Unfortunately, this does not incorporate compression in its assessment of operative specimens. As such, we designed this simple appliance to address this issue. It will not improve the accuracy of a suboptimal procedure, rather it complements the use of SM and helps to limit excessive surgery. Its usefulness as such cannot be directly quantified. However, initial experience suggests it is a helpful adjunct to SM and may potentially improve its diagnostic function.
We believe that the introduction of this device into our routine practice within a specialist Breast Unit will lessen the requirement for multiple views of the specimen at diagnostic/therapeutic excision.
Copyright 17 October 2004
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