Steve H. Parker, MD Kenneth D. Hopper,

#{149} Jeffrey

MD

D. Lovin, MD #{149} William E. Jobe, MD F. Yakes, MD #{149} Brian J Burke, MD

Stereotactic

Breast

Biopsy

G

terms: 00.1299

Breast

#{149}

Radiology

Biopsies,

technology

Breast

neoplasms,

#{149}

neoplasms,

#{149} Breast, diagnosis,

localization,

ing

lesions

are

referred

calization

followed

sy.

a relatively

While

From

tinely (1,2),

safe

the

Radiology Army

Associates,

Medical

Center,

our

in such

with

inability

biopsies

to sample

the

accuracy. available provided

to apply

biopsy

fidently

our

gun lesion.

conducted mammography

with

fine-needle

Cob

with

breast

and

con-

a mammognaphically

tions tactic

Englewood,

The advent stereotactic us with the

have

Recent with

aspiration been

Cob

(S.H.P.,

(S.H.P.,

J.D.L.,

investiga-

use of stereoin conjunction

W.E.J.); J.M.L.,

biopsy

successful

in en-

diagnosis numbers

but of

Department K.D.H.,

of Radi-

W.F.Y.,

B.J.B.);

of Radiology, Pennsylvania State University, Milton S. Hershey Medical Cen(K.D.H.). From the 1989 RSNA scientific assembly. Received January 9, 1990;

revision

March

requested

14; revision

#{149}

received

and

accepted

May

8. Address

reprint

requests

to

8200 E Belleview, Suite 124, Englewood, CO 80011. herein are the private views of the authors and are not to the views of the Department of the Army or the Depart-

of Defense. RSNA, 1990 See also the articles by Hopper et al (pp 671-676), Poster et al (pp 677-679) and the editorial by Bernardino (pp 615-616) in this issue.

Gun’

to those

concomitant consecutive opsy

of the

corresponding,

surgical patients

biopsies referred

in 103 for bi-

of mammographically

nonpalpable

sugges-

lesions.

MATERIALS

AND

METHODS

During a 13-month period, under a protocol approved by the clinical investigation/human use committee and after informed consent was obtained, 103 stereotactic needle core breast biopsies were performed. After the needle core biopsy and localization wire placement, the patient underwent traditional surgical excibiopsy.

The

surgical

biopsies

were

performed by one of three surgical residents, all under direct staff supervision. All needle core biopsies by one of four radiologists

ologists with

lesions

experience

to the

target

suggestive

breast

sies

sional

and the Department ter, Hershey, Penn

S.H.P., Radiology Imaging Associates, The opinions or assertions contained be construed as official or as reflecting

MD

false-negative results and cases with insufficient tissue sampling (4-6). We therefore decided to compare results of stereotactic needle core gun biop-

tive

by radiologists enjoyed improved

with pinpoint of commercially mammography

bi-

Aurora,

biop-

procedure,

the use of an automated biopsy device (3). We were frustrated in our initial attempts to utilize the instrument for breast biopsies, however, because of

00.125

Imaging

bo-

performed and we have

success

1990; 176:741-747

Fitzsimons

needle

by surgical

abling breast cancer have had significant

1

for

there is frequently some delay in anranging the biopsy, the cost is significant, and there is some potential for complications and disfigurement. Accurate, dependable needle biopsies would eliminate or considerably reduce these drawbacks. Percutaneous biopsy of various sites other than the breast are rou-

(FNAB)

ology,

M. Luethke,

a Biopsy

REATER

means opsy, 00.3

with

utilization of breast screening in asymptomatic women is leading to the discovery of an even-increasing number of nonpalpable lesions suggestive of cancer. Patients with more ominous-appear-

One hundred three patients underwent stereotactic breast biopsy with an 18-, 16-, or 14-gauge cutting needle and a biopsy gun. After biopsy, a localization wire was placed and surgical biopsy performed. There was agreement of the histologic results in 89 cases (87%) including 14 of 16 cancers (87%) (x 0.806). The gun biopsy yielded the correct diagnosis in four cases involving a lesion (including one cancer) that was missed at the surgical biopsy. Nine cases in which the lesion was missed at gun biopsy can be related to insufficient needle size, the greater difficulty in using one of the two stereotactic devices, and early inexperience with the technique. A 14-gauge needle was used in the last 29 biopsies, the results of which agreed with the surgical pathologic findings in 28 cases (97%). With greater experience, stereotacticguided large-gauge automated percutaneous biopsy may prove to be an acceptable alternative to surgical biopsy in women with breast masses suspected at mammography. Index

#{149} James

#{149} Wayne

and the

two

Biopty

Urobogicab, by Radiplast, junction with

were (two

radiology gun

Covington, Uppsala, 18-, 16-,

performed staff radi-

residents)

(distributed

by

Bard

Ga; manufactured Sweden) or 14-gauge

in conBiopty-

cut needles. Sixty-five patients underwent biopsy with use of 18-gauge needies, nine patients with 16-gauge needles, and 29 patients with 14-gauge needles. One hundred one patients underwent biopsy with the “long-throw” Biopty gun, which has a 2.3-cm needle excursion. Two patients underwent biopsy with the “short-throw” Biopty gun, which has a 1.15-cm needle excursion. For the first 30 biopsies, stereotactic guidance was provided by the Senographe Mammographic System 600T (GE Medical Systems, Milwaukee) coupled with the Steneotix computerized stereotactic needle localization device (GE Medical Systems). The biopsy method used with this device is described elsewhere (7). Because of the logistical problems nebated to the use of the Biopty gun with the Senographe unit, we switched to the Mammotest Stereotactic System (Fischer

ment

725-727),

and

Elvin

et al (pp

Abbreviation:

FNAB

fine-needle

aspiration

biopsy.

741

Figure

1. Mammotest lies comfortably

Patient

stereotactic system. on the table with

her breast placed through an opening in the table. All hardware is located beneath the table, with the compression plate (solid anrow), stereotactic apparatus (open straight arrow),

biopsy

gun,

curved

arrow)

out

gun

is firmly

mounted bility

on of

locked depth

unwanted

and of

housing

patient’s

into slide, gun/needle

a.

(open sight.

Biopsy

the housing reducing

the

possi-

displace-

ment.

Imaging, Denver) after the first 30 patients. The remaining 73 patients underwent biopsy with this system. The Mammotest unit allows the patient to lie prone on a table with her breast protruding through an opening at the front of the table. The compression plate, x-ray tube, stereotactic apparatus, and the biopsy device are all located underneath the table, out of sight of the patient and free from encumbrances (Fig 1). The manufacturer designed a dedicated housing for the Biopty gun that attaches to the depth slide on the stereotactic apparatus. In addition, software was incorporated that provides an audible and visual warning on the digitizer if the 2.3-cm excursion of the needle would result in the needle striking the Bucky plate. The first step in the Mammotest biopsy sequence is to obtain a mammographic bocalizing view that includes visualization of the whole breast to ensure that the besion is indeed within the aperture of the compression plate. After confirmation, the breast within the aperture is cleansed with povidone-iodmne (Betadine; Purdue Frederick, Norwalk, Conn). Stereo views are then obtained by swinging the x-ray tube 15#{176} off center in each direction. The two stereo images are exposed adjacent to each other on the same film (Fig 2a). Computer-generated coordinates derived from the stereo images are dialed into the stereotactic unit, and the Biopty gun with needle already loaded is aligned automaticably on the proper trajectory. The needle is then advanced (by moving the gun housing) through a small skin nick to the calculated depth, and stereo views are obtamed again to confirm that the needle is poised over the lesion (Fig 2b). The needle is then backed up at least 2 mm to ensure proper postfine positioning of the sample notch within the lesion (3). The gun is fired, and a final set of stereo views ensures that the needle has tra742

#{149} Radiology

b.

C.

Figure

2.

Aligning

are obtained, aligning

and

the

gun

the

gun

and

the coordinates and

needle

document

that

the

needle

and

generated

onto

the skin nick to the computed needle tip is over the lesion.

needle the

proper

crements All biopsy

to posteriorly

from the center passes traverse

these

trajectory.

needle

views (b)

The

position.

are dialed needle

depth, and stereo views are obtained (c) Final set of stereo views is obtained has

traversed

the

versed the lesion (Fig 2c). The needle is removed, and the core tissue obtained is placed in fonmalin. Three to four passes are made through the lesion to canvass it anteriorly

confirming

from

in

measured

in-

of the lesion. the same skin

nick.

After the stereotactic biopsy, a conventionai needle localization hook-wire was placed by using the same coordinates as

(a) Stereo

into

is advanced

again after

views

the main

unit

through

to confirm that the gun is fired

the to

lesion.

used for the needle core biopsy. A conventional mammogram was obtained to ensure adequate wire placement. The patient then underwent outpatient surgical excisional biopsy under local anesthetic. The local anesthetic occasionally had to be supplemented by intravenously administered sedatives. The histopathobogic specimens from each biopsy were then compared by the same pathologist to evaluate for agreement.

September

1990

There were 20 with agreement from the needle specimens in 41 nomas diagnosed missed

fibroadenomas, between findings core and surgical cases. Four fibroadeat surgery were

at stereotactic

gun

biopsy.

One of the fibroadenomas was missed at gun biopsy because the stereotactic machine was out of calibration. Another fibroadenoma was missed

a. Figure

b.

3. Comparison of gun needle core and surgical histopathologic cancer. (a) Intraductal carcinoma from the gun core specimen (arrows). carcinoma from surgical excisional biopsy specimen (arrows).

specimens of breast (b) Same intraductal

because

of patient

movement.

A third was most likely missed as result of displacement of the lesion away from the advancing needle The fourth fibroadenoma missed gun biopsy was probably also due lesion movement. Two fibroadenomas

diagnosed

missed

at gun

at surgery

biopsy

(Fig

a tip. at to

were

4).

In the 55 cases of fibrocystic change, the findings from the needle cone and surgical specimens were in full

agreement

in 37 and

partial

agreement in 14 cases. Full agreements were tabulated when three or more of the elements of that panticulan area

of fibrocystic

change

were

correlated (Fig 5). If only one or two elements were correlated, then the case was tabulated as a partial agreement. There were four cases in which the gun biopsy specimen failed to contain any elements of fibrocystic change and contained only normal breast tissue. These may be a reflection of the random distribution of fiRESULTS

biopsy

The results from 102 of the 103 patients who underwent steneotactic gun biopsy were available for companison with results from surgical excisional biopsy. (Needle biopsy specimens from one patient were lost.) Samples sufficient for histobogic analysis were obtained by means of stereotactic needle core biopsy in 101 of the 102 patients (99%). The case in which insufficient tissue was obtained was one of the two biopsies performed with the “short-throw” Biopty gun and an 18-gauge needle. In 12 other cases there was disagreement between the histopathobogic diagnoses reached with the two biopsy methods. In eight of those cases, adequate tissue was obtained with the gun biopsy, but the diagnosis made was different from that made from the surgical specimen. In the other four cases, the results at gun biopsy corresponded to the mammographic findings, but these findings were not seen at surgery. For the 102 patients, ic = 0.806 reflecting strong agreement between the stereotactic needle core and surgical excisional Volume

176

#{149} Number

3

ing

results

brocystic breast

(Table).

There were 16 cancers ductal, two intraductal,

mucinous

carcinoma)

(13 infiltratand one

with

agree-

ment between findings from the needle and surgical biopsy specimens in 14 cases (Fig 3). The gun biopsy core specimen did not include a small focus of intraductal carcinoma found in a subsequent permanent surgical specimen. This was probably due to improper calibration of the stereotactic machine. In the other case of cancer without correlation, the stereotactic gun biopsy yielded a diagnosis of mucinous carcinoma that was missed at the ensuing surgical excisional biopsy.

The

presence

of cancer

was

bat-

en substantiated by means of histologic examination of the surgical specimen after modified radical mastectomy. In another case, the gun biopsy core did not include a focus of lobular carcinoma in situ found in the surgical specimen that was obtamed in a region remote from the area of fat necrosis that was causing the mammognaphic abnormality. The fat necrosis was successfully diagnosed from both the gun core and the frozen surgical material.

change tissue.

within

normal

There were 1 1 other diagnoses in the series including six cases in which only normal breast tissue was found in both the stereotactic and surgical specimens. There were two cases of intramammary lymph nodes with good correlation of results between biopsy techniques. In fact, in one of the two cases, results correlated so well that the pathologist believed he could identify the defect from the gun cone on the surgical specimen (Fig 6). In one case with a radial scan and one with an area of fat necrosis,

results

Finally, a cicatnix tactic biopsy was Subjectively,

also

correlated

well.

diagnosed at stereomissed at surgery. it was

noted

that

breast tissue (unlike prostate, liver, or kidney) was frequently fatty and friable and tended to fragment and disintegrate when placed in formalin. In consultation gists, it became

clean

with our pathobothat the histo-

logic with

correlations were not perfect the 18- or even 16-gauge nee-

dles,

especially

in cases

of fibrocystic

change. It was decided to use larger-gauge needle. Therefore, 74 patients underwent biopsy Radiology

a still after with #{149} 743

b.

a. Figure

4. Fibroadenoma missed at surgical biopsy. (a) Stereo views demonstrating over cluster of microcalcifications (arrows). (b) Gun core sample showing

poised

tissue (straight arrow) and Radiograph of surgical cifications. At histopathobogic

microcalcification specimen showing examination,

(c)

sue without

evidence

of the sclerotic

(curved arrow) of a sclerotic end of localization hook-wire the specimen contained only

needle the fibrous

fibroadenoma. but no microcalnormal breast tis-

fibroadenoma.

the 18- and 16-gauge needles, the remaining 29 underwent biopsy with 14-gauge needles. With the 14-gauge needle there was only one case of fi-

bleeding occurred, the 14-gauge needle.

brocystic of results.

tis occurred, and all were successfulby treated with antibiotics. It is not possible to determine with certainty

change without correlation Evaluation of the 14-gauge

needle vealed more

cores by our pathologists respecimens that were much consistent and uniform than

those

obtained

with

the

gauge needles. The one documented broadenoma missed

was controlled pressure. Three

whether from

case of a fiat gun biopsy re-

sulted from breast movement with use of the Senographe Stereotix unit. No unwanted patient on gun/needle

movement was observed with use of the Mammotest unit. In the two cases of documented lesions (one fibroadenoma and one cancer) that were

tion

of surgical

and

we have

As

mammography

No

ening

None

of the

103

patients

suffered

immediate significant complications. Two vasovagal reactions occurred during use of the Senographe Stereotix; one caused patient and breast movement resulting in a gun biopsy miss.

No

reactions

Mammotest 744

Radiology

#{149}

unit.

occurred

No significant

with

the

biopsy, in nearana-

more

commonplace lesions

are

for an increasing

the

to detect

would

screening

compound

method ogists noses

form opsies,

more the

number

of result bow-

for breast biopsy cancers (9), and this the increase in biCurrently, the

opsy performance. most common means is surgical excision.

sive, able,

and

will most likely some advocate

threshold earlier

be-

detected,

time-consuming, and occasionally

of breast This is an

biopsy expen-

uncomfortunreliable

of diagnosis (8,10). As radiolwhose robe it is to make diagand, more specifically, to per-

image-guided it should

percutaneous be natural

that

this

biwe

adapt our techniques to the diagnosis of breast disease. Most investigators have focused on FNAB in an attempt

goal

(4-6,11-13).

mammognaphic the theoretical

cy of skinny

case

DISCUSSION

need

en-

to accomplish

Steneotactic has improved

needle

guidance accura-

placement,

but

FNAB results in a substantial number of cases in which insufficient tissue obtained (6%-47%) and in a significant number of false-negative findings

breast biopsies (8). In addition,

were

needle

complication biopsies of other

solved by checking the calibration with a phantom prior to each biopsy. problems

excisional

of an infectious ly 1,000 gun tomic sites.

suspicious

with the Senognaphe SterThe time required for the has decreased with expenithat the average time for (excluding placement hook-wire) is now ap20-30 minutes.

resulted

biopsy,

yet to log a single

comes

calibration

cases

core

C.

or surgical biopsy. Howis a known complica-

missed at gun biopsy, calibration problems occurred with the Mammotest unit. These problems were

countered eotix unit. procedure ence such the procedure of localizing proximately

of

with manual of local celluli-

three

needle

localization, ever, cellulitis

smaller-

easily cases

these the

even with use Minor oozing

(1%-31%)

(14).

In addition

with

FNAB, the occasional false-positive results (1% or less), the poor ability make definitive benign diagnoses, and the inability to distinguish between in situ and invasive carcinoma have made surgeons and others reluctant

to rely

on

is

to

percutaneous

breast biopsy findings to make definitive treatment decisions (14-16). Compounding the above problems is the fact that cytopathobogy is a difficult art and science that is not available in its highest form in many institutions.

Since

many

believe

that

aspiration biopsy will not achieve a high degree of success without the constant availability of a highly skilled

and

trained

cytopathobogist,

attempts to perform breast FNAB at many institutions are likely to be unsuccessful (4,14,17). Many pathologists and surgeons believe cone tissue is superior to matenial obtained from needle aspiraSeptember

1990

that

the

14-gauge

sistently

a. Figure

b. 5.

Histopathobogic

ent elements.

gun

core

specimen

of fibrocystic

changes

showing

several

differ-

(a) Gun

core specimen showing multiple ectatic ducts (straight arrows) brosis (curved arrow). (b) Another portion of the same core shows ductal hyperplasia straight arrows) and papilbomatosis (open curved arrow). These findings are difficult, impossible,

to

detect

at aspiration

and fi(open if not

biopsy.

needles

provided

the

most highest

conquali-

ty, intact cores. We also thought that the larger cores would further decrease the chances of sampling error. We continued to use the Biopty gun rather than the conventional 14gauge needle because of the ease of use of the gun, the decreased patient discomfort and increased specimen quality and integrity due to the splitsecond sampling, and the ability of the gun to pierce both hand and mobile breast lesions before they have a chance to move out of the path of the needle. Despite the use of steneotactic guidance, with its theoretical accuracy of 1 mm in needle core gun biopsies,

there

were

still

nine

cases

in

which failed

a. Figure 6. (a) Surgical of resultant

b. Comparison

of histopathobogic

specimen showing gun core specimen.

specimens

gun core defect

tion biopsy, since it provides histologic information permitting definitive benign diagnoses and more complete characterization of mabignant lesions (1,2,15,16). When a definitive benign diagnosis (eg, fibroadenoma) can be made, open biopsy can be confidently avoided. The rebiabbe, complete, preoperative characterization of the type of malignant lesion present allows for the appropniate tailoring of the patient’s treatment without repetition of biopsy when and if surgery is performed. One of the reasons that radiologists might not have routinely used largegauge core needles in breast biopsy in the past is the theoretic increase in morbidity that is seen when largegauge needles are used elsewhere in the body (1,2). In adapting FNAB techniques to breast biopsy, investigators naturally used the needles and the techniques that they had honed during their experience in biopsy of other areas of the body, apparently without considering the fact that the breast is quite forgiving and virtually devoid of structures that could result Volume

the stereotactic gun biopsy to yield the diagnosis that was successfully made at surgical biopsy. However, we believe there were several possible explanations for these misses. First, our definite inexpenience with two different stereotactic machines used during our study had to be overcome. In addition, our pathobogists had to gain experience and confidence in handling and interpreting the cones. Second, because the 18-gauge needles used in the first 64 patients did not always obtain full

176

#{149} Number

3

of an

intramammary

in the center

lymph

of the lymph

node.

intact

node.

(b) Portion

cores,

lesions

in significant morbidity if tnansgressed by a core biopsy needle. Also, there have been conflicting reports regarding the relative efficacy of aspiration needles versus core biopsy needles in the breast (18-21). The studies purporting superior resuits with FNAB, however, compared multiple skinny needle passes to one core needle pass and were performed without an automated, rapid-fire cone

conjunction with it did not reliably tissue (22). Third,

biopsy

nomas

instrument

or pinpoint

imag-

ing guidance (neither stereotactic ultrasound [US] guidance). They failed to address the poor ability FNAB

results

to enable

nor also of

a definitive

benign diagnosis, an important consideration in breast biopsy as the majonity of lesions sampled are indeed benign. Without definitive benign diagnoses, it is impossible to differentiate between a potential false-negative result due to a sampling error and a true-negative result such as fibnoadenoma, sclerosing adenosis, or fibrocystic

Because

change.

the

breast

sists

of extraordinarily

fatty

tissue,

our

frequently friable

pathologists

conand

found

may

not

have

been as thoroughly canvassed as we believed from the stereo images. Also, the short-throw gun was used on two occasions until we realized, in another study, that obtain high-quality we experienced

significant calibration problems on at least two separate occasions. Fourth, patient movement causing subsequent breast movement after the mitial

stereo

calculations

were

made

ne-

suited in inaccurate coordinates in two cases. Fifth, we realized that at least one and possibly two fibroadewere

missed

because

of lesion

movement within the breast. This seems to be a frequent characteristic of fibroadenomas, confirmed under direct visualization during our USguided biopsies, since they do not appear to be firmly anchored in the breast. Therefore, as a needle is manually advanced toward the lesion, it can rotate or slip out of the path of the needle. Presently, if we suspect that a lesion is moving away from our needle tip, we back the tip up as much as 1.5 cm from the lesion. Then, when the gun is fired, the split-second the needle sion before

rapid-fire projection of allows it to pierce the leit can slip out of the way.

Radiology

#{149} 745

Finally, ity

it is apparent

plays

a role

that

in breast

serendipdiagnosis.

In

other words, there are occasions when the surgeons unwittingly make a diagnosis with their generous sungical sample that may have nothing whatsoever to do with the mammographic finding. We believe the sungical diagnosis of lobular carcinoma in situ in our series was just such an example; the mammognaphic finding in that case was fat necrosis. There is nothing that can be done about lesions missed at stereotactic gun biopsy that surgical

were

serendipitously

biopsy;

however,

seen the

nique is actually a further extension of the “minimal volume excision” approach advocated by Gallagher et al (27); however, it is much more expeditious and eliminates surgery entinely for benign lesions. Thus, the potential for psychological stress and physical trauma is lessened considerably.

A beneficial by-product of needle cone breast biopsy is the nearly immediate feedback the radiologist neceives regarding the actual histopathologic makeup of the mammographic finding will naturally

at

other

in question. improve future

This mam-

causative factors in our misses can be addressed and if these factors are eliminated, the success rate should improve further. In determining whether stereotactic gun biopsies might be performed as an alternative to surgical excisional biopsies, one should also take a close look at surgical biopsies, which have been referred to in some instances as “ritualistic rather than realistic” (15). Although surgery is considered a standard of reference, it should not be mistaken for perfection. On the contrary, needle localization breast biopsy is a semiblind operation with a technical difficulty that should not be underestimated even by the most experienced surgeons (23). The lesion miss rate is as high as one in five procedures with local anesthesia (10). Considerable bleeding can occur during a surgical biopsy that can obscure the operative field and preclude confident excision of deep lesions (23). Also, if the wine inadventantly dislodges, migrates, on is transected, the surgeon can become disoriented and excise the wrong tissue (24,25). Finally, lack of communication between the radiologist who has placed the localizing wire and the surgeon can result in a surgical

mographers’ interpretation abilities, and a less experienced mammographer will become highly competent much more quickly. As noted by Hall, “no book or lecture can substi-

miss (26). Surgical time-consuming,

vorable cost-benefit analysis that occurs when benign to malignant ratios rise with the inclusion of such be-

biopsies potentially

are

also nerve-

racking, and require a great deal of resources (8). The delays frequently encountered impose a psychological stress on the patient awaiting the procedure. Combining the time in the radiology and surgery departments,

the

needle

localization

surgical

tissue

with

only

746

#{149} Radiology

(8). and

surgery

may

have

been

performed

in

the process of the biopsy. Now such patients might still go straight to sungery; however, this sequence may change as the trend toward more conservative

ment tinues.

and

of primary Acquisition

nonsungical

breast

treat-

cancer

con-

of a definitive

histologic needle core biopsy specimen may be desirable prior to consideration of any type of treatment, surgical on otherwise. Currently there is some debate about the advisability of short-interval follow-up of less suggestive or “probably benign” lesions versus recommendation of immediate surgical biopsy (28). The rationale for short-interval

for

follow-up

surgical

biopsy.

is the

With

approach

a

to the

definitive

tion

suits,

and

and

the

amount

of sun-

References 1.

Charboneau

JW,

Reading

CC,

CT and sonographically opsy: current techniques tions. 2.

AJR

1990;

1989; Parker

rected

TJ.

154:1-10.

153:929-935. SH, Hopper

KD.

percutanelesions. AIR

Yakes

WF,

JL, Carter

TE. biopsies

percutaneous

sy gun.

Welch

guided needle biand new innova-

Gazelle GS, Haaga JR. Guided ous biopsy of intraabdominal

MD, Ownbey Radiology

1989;

Gibson

Image-diwith a biop-

171:663-669.

4.

Dowlatshahi K, Gent HJ, Schmidt R, Jokich PM, Bibbo M, Sprenger E. Nonpalpable breast tumors: diagnosis with stereotaxic localization and fine-needle aspi-

5.

Ciatto

ration.

6.

Radiology

5, Del

7.

lesion:

breast

Hall tial

core

Med

F.

1986;

Radiology C.

in 2,594

Stereotaxic

mammogralesions.

SH, Jobe WE, Luethke Stereotactic percutanebiopsy:

technical

experience.

Screening

problems

Nonfine-

non-palpable

tion and initial 1990; 3:135-143. 8.

P.

1:1033-1036.

Lovin JD, Parker JM, Hopper KD. ous

G, Auer

biopsy 1989;

Bravetti stereotaxic

cytology.

detected

Lancet

170:427-433.

MR.

needle aspiration 1989; 173:57-59. Azavedo E, Svane phically

bi-

1989;

Turco

breast

fine-needle

whether or not it is performed with administration of general anesthesia and whether it is performed on an in- or outpatient basis. The cost of a stereotactic gun biopsy is approxi-

utiliza-

screening

reduce

palpable

on

increasing

required for therapy of the cancers diagnosed (29). Stereotactic mammography allows pinpoint needle placement, and the large cones obtained from 14-gauge needles furthen decrease the possibility of sampling error. The large cores also ebimmate the need for an experienced cytopathobogist and allow for histologic evaluation permitting definitive benign diagnoses and complete charactenization of malignant lesions. Utilization of a mechanized biopsy device eliminates the need for mastery of difficult aspiration techniques with the push of a button. It is therefore our opinion that steneotactic breast gun biopsy overcomes many of the problems associated with FNAB and may prove to be a cost-effective, expedient, and dependable alternative to surgical biopsy. U

histo-

opsy in Denver varies between $1,217 and $2,673 depending

With

gery

the

pathologic diagnosis of mammographic lesions could be forthcoming. The cost of a surgical excisional

$675.

of mammographic

the resultant increase in performance of breast biopsy, the national cost of surgical biopsy could rise considerably. It is therefore important that cost-effective means of breast cancer diagnosis are identified and utilized. Stereotactic gun biopsy of the breast may help fill this need. In conclusion, to justify a percutaneous breast biopsy triage system for suggestive nonpalpabie mammographic lesions, the system must be extremely accurate, reduce on eliminate surgical biopsy with benign re-

3.

unfa-

lower cost, discomfort, and psychological trauma associated with stereotactic gun biopsies, a more aggressive

and

skin nick, leaving no scar. It can be performed quickly and easily after the original mammogram is obtamed, even the same day. This tech-

of teaching” puzzling

sometimes highly suggestive mammographic pseudolesions that can appear after surgical biopsy should no longer be a dilemma (19). Previously, in patients with highly suggestive lesions or obvious mammognaphic cancers, the definitive

sions

surgical excisional biopsy may requine up to 3 hours. Postoperative hematoma, cellulitis, and poor cosmesis can result. By contrast, a stereotactic gun biopsy obtains

tute for this type Also, the frequently

mately

adapta-

Breast

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15.

21.

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3

Vorherr

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tissue

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22.

biopsy. 23.

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needle

pre-operative

of the

biopsy

26. with

in the diagnosis in breast

YH.

IM, needle

diagnosis masses.

Schick

Aspiration

to Tru-Cut

the

27.

28.

P. Nie-

cytology biopsy Surg

is sus-

1982;

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of clinically Ann

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Sundaram M, Wolverson MK, Heiberg E, Pilla T, Vas WG, Shields JB. Utility of CTguided abdominal aspiration procedures. AJR 1982; 139:1111-1115. Elston CW, Cotton RE, Davies CJ, Blamey RW. A comparison of the use of the “Tnt-Cut”

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