MRI vacuum-assisted breast biopsies

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REVIEW

/

Breast

imaging

MRI

vacuum-assisted

breast

biopsies

R. Plantade

a,∗

,

I. Thomassin-Naggara

b

a_Nice_Europe_Imaging_Centre,_15,_rue_Alberti,₀₆₀₀₀_Nice,_France

b_Department_of_Radiology,_Tenon_Hospital,_Paris_Public_Hospitals_Health_Service_(AP—HP), PierreetMarieCurieUniversityOncologyInstitute,4,ruedelaChine,75020Paris,France

KEYWORDS Breastcancer; Vacuumbiopsies; MRI-guided; Targetedultrasound; Secondlook examination

Abstract Theindications,technique, resultsandlimitationsofMRIvacuum-assistedbreast biopsiesarediscussedfromareviewoftheliterature.Thiswasinitiallyahome-grown tech-niqueanditsdevelopmentwassloweddownbyseveralfactors.Asaresultofmajortechnical advances,ithasbecomeareliableandveryconsistentprocedurewithalowrateof underes-timation.ItisnowanundisputedtechniquewhensuspiciousMRIenhancementisseenwithno correspondingmammographyorultrasoundfeatures.

Introduction

BreastMRI developedinthe 1980s.It isasecond lookexamination althoughthe devel-opmentofscreening,patientandmediademandandimprovedaccesstomachineshave promotedthewidespreaduseofthetechnique.

Itoffersexcellentsensitivity,onaverageof0.9(0.88—0.92)[1]andcanidentifyoccult

inﬁltrativecancersunderacentimeterinsize(whenclinicalexamination,mammography

andultrasoundarenormal).

It has an average speciﬁcityof 0.72 (0.67—0.77) [1], which depends greatly onthe

indications.Thesearenowwelldeﬁned[2].

Eveniftheseindicationsandtechnicalqualitycriteriaarefollowedhowever,contrast

enhancementsuspectedofbeingmalignantcanonlybeconﬁrmedhistologically.

MRI-guidedpreoperativelocalization[3—9]andsampling(ﬁneneedleaspiration

cytolo-gies,corebiopsies[8,10]andthenvacuum-assistedbreastbiopsies[11—13])havetherefore

beendeveloped.

Abbreviations:MRI,magneticresonanceimaging;CE,contrastenhancement;BI-RADS,breastimagingreportingsystemanddatasystem; HRT,hormonereplacementtherapy;PPV,positivepredictivevalue;NPV,negativepredictivevalue;MDT,multidisciplinaryteammeeting; T,tesla;G,gauge(cannuladiameter);CAD,computer-assisteddiagnosis;HAS,HauteAutoritédesanté(FrenchNationalHealthAuthority); ADH,atypicalductalhyperplasia;DCIS,ductalcarcinomainsitu;Vs,versus.

∗_{Corresponding}_author.

E-mailaddress:ronanplantade@gmail.com(R.Plantade).

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Targeted

examinations

When suspicious CE (BI-RADS 4 or 5 or even 3) is found on a breast MRI performed for a recognized

indica-tion[14] and no corresponding abnormalities are present

on a conventional assessment, the average malignancy

rate is 30% (20 to 62%, depending on recruitment type)

[15—24].

Thisﬁgureincreaseswiththesizeoftheareaof

enhance-ment (3% for<5mm versus 31% for>20mm) [24] and is

reported to be greater if a corresponding

mammogra-phyorultrasoundabnormalityispresent[15,21,22,35—37]

(Table1).

Targeted investigations (mammography and/or

ultra-sound)are then performed in order toinvestigate for an

occasionallysubtle abnormality, which is not seen onthe

initialbreastassessment[22].

Ideally,thisisperformedbytheradiologistwhocarried

outtheMRI.Ifnot,theradiologistwhodoescarryoutthe

investigationshouldhaveaccesstoallof theinformation,

i.e.alloftheimageswrittentoCD,thesiteonatopogram,

reconstructions(MIP, MPR)anddistances fromthe various

landmarks[46—49].

The radiologistneedstoknowthe shapeof theCEand

take account of its change in position between MRI and

mammographyor ultrasoundandbeawarethatthe

situa-tionbecomesincreasinglydifferentwithlargerbreastsand

thefurtherawaytheCEis fromthenipple, theonlyﬁxed

anatomicalbreastlandmark.

Other landmarks such as a benign or cystic

tis-sue structure, scar or macrocalciﬁcation, etc. can be

used.

Although there is consensus agreement on its use,

this guided examination has not been carried out

rou-tinely [21,23,50] or has not been described [26] in some

series.

Targeted

ultrasound

Theexaminationneedstolookfornodules,butalsoapoorly delineatedareaoftissue(seenparticularlyinnon-massCE), a complex cyst or local disharmony (texture, outlines or echogenicity).

Ultrasoundcorrelationsareusuallyfound inmalignancy [21,22],massCE[15,21,22,35,38,39,43,46,51],target[39],

ormicronodularlesions[39],andBI-RADS4(vs5)[38],T2

hyperintensityorimplants.

It is reported not to correlate with breast density

[15,16,39]orsizeoftheCE[21,42]asultrasoundresolution

isgreaterthanthatofMRI.

Some authors do report however that the correlation

is greater for CE>10mm [38,39] and BI-RADS 5 (vs 4)

[39].

Itisdescribedin61%ofcases(23to89%)withanaverage

malignancyrateof34%(16to65%)[15—22,35,38,40—45].

Nakano[52]greatlyimproved thedetectionrate(90vs

30%)combiningultrasound-MRIandimagefusion,although

the30%rateisverylowcomparedtootherpublished

stud-ies.

If ultrasound is negative (39%), the average

malig-nancyratefalls to17%(2to54%)[15—22,35,38,40—45,49]

explainingtheneedforhistologicalproofincludingthecase

ofsmallrelativelyunsuspiciousCE[43].

Further

ﬁlms

AnenlargedfilmcenteredontheCEquadrantcanidentify fine microcalcifications, which are notvisible or not con-sidered significant onthe initial conventional assessment, togetherwithsubtle architecturaldisorganization or local asymmetryindensity.

Theseﬁlmsareparticularlyusefulfornon-massCE. AccordingtoThomassin[36],themalignancyrateisover

90%incasesofnon-massenhancementover20mm insize

accompaniedbymicrocalciﬁcationsinthesamearea.

Management

Ifaconcordantabnormalityisfoundtheindicationforbiopsy isbasedontheworstappearances(MRI,ultrasoundor mam-mography)[51].

Thisshouldthenbeperformedstereotacticallyorunder

ultrasoundguidanceasthesearethemostaccessible,fast

andleastexpensiveguidancemethods.Alandmarkisthen

leftinplace.

In2005, Taourel [53] proposedlabelingthe biopsy site

withinsitugadoliniuminjection.

Currently, however, a clip is routinely applied

[47,48,51,54] and the concordant location of the CE

and clip is checked with a high TE T1 weighted echo

gradientMRIimage[48,51].Anatomicallandmarksare

gen-erally sufﬁcient, although in uncertain cases intravenous

gadoliniummayberequired.

ArepeatMRIafter ashortperiodoftime(6months) is

recommendedifthecorrelationisgoodandthehistological

resultisbenign[48,51].

Revision surgery is required for a borderline lesion or

carcinoma.

If no concordant abnormalities are seen in a low risk

situation (when the indication is debatable on MRI) and

enhancementisnotsuspicious[55],arepeatMRIcanbe

pro-posed6monthslaterafterdecongestanttherapyorstopping

HRT.

In all of the other situations listed below,

MRI-guidedrepeathistologyisrequired[11,25—27,48,50,55—60]

(Table2)(Fig.1):

• BI-RADS 3 in women with mutations or in ipsilateralor

contralateralcancer[37,46,50,64]asthePPVof MRI

BI-RADS3isgreaterthanthatofmammographyorultrasound

(<2%)[43,45,65];

• BI-RADS4or5[11,21,26,32,33,66,67];

• pooragreementbetweenCEandtheimagefoundor

biop-sied ontargeted examination (clip distant,unexpected

histologicalresult)[48,68].

Whereverpossible,thedecisionismadefollowinganMDT

[50,69,70].‘‘Simple,intelligibleandreliable’’information

isthengiventothepatientabouttheprocedure,limitations,

risksandthe‘‘patient’sfreeinformedconsent’’isobtained

accordingtothetermsofarticle35oftheDeontologyCode

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vacuum-assisted

breast

biopsies

781

Table1 ResultsofthetargetedultrasoundafterMRI.

Authorsreferences Year Context OnMRI,numberof Numberof2nd

lookultrasounds performed

Onultrasound,numberoflesions

Patients Lesions Cancers Visible Including

cancers

Occult Including cancers

LaTrenta[15] 2003 Pre-treatmentorfollowup 64 93 19(20%) 93(100%) 21(23%) 9(43%) 72(77%) 10(14%)

Deurloo[16] 2005 Pre-treatmentassessment 48 50 20(40%) 39(78%) 19(49%) 12(63%) 20(51%) 6(30%) Sim[17] 2005 Highfamilialrisk 43 48 12(25%) 48(100%) 32(67%) 11(34%) 16(33%) 1(6%) Beran[18] 2005 Pre-treatmentassessment 52 73 45(62%) 73(100%) 65(89%) 42(65%) 8(11%) 3(35%) Shin[19] 2007 Pre-treatmentassessment 62 69 26(38%) 38(55%) 27(71%) 15(56%) 11(29%) 3(27%) Linda[20] 2008 Various 159 173 49(28%) 173(100%) 142(82%) 46(32%) 31(18%) 3(10%) DeMartini[21] 2009 Various 155 201 60(30%) 167(83%) 76(46%) 27(36%) 91(54%) 20(22%) Carbognin[38] 2009 Various 62 17(27%) 62(100%) 44(71%) 12(27%) 18(29%) 5(31%) Meissnitzer[39] 2009 Various 361 519 121(23%) 519(100%) 290(56%) 87(30%) 229(44%) 34(15%) Destounis[40] 2009 Pre-treatmentassessment 152 196 47(20%) 182(93%) 128(70%) 39(30%) 54(30%) 8(16%) Abe[22] 2010 Various 158 202 44(22%) 202(100%) 115(57%) 33(29%) 87(43%) 11(13%) Luciani[18] 2010 Pre-treatmentassessment 46 55 31(56%) 55(100%) 42(76%) 24(57%) 13(24%) 7(54%) Candelaria[42] 2011 Various 83 131 45(34%) 131(100%) 88(67%) 27(31%) 43(33%) 18(42%) Laguna[43] 2011 Pre-treatmentassessment 123 37(30%) 123(100%) 76(62%) 26(34%) 47(38%) 11(23%) Ha[44] 2011 Pre-treatmentassessment 33 34 7(21%) 34(100%) 12(35%) 6(50%) 22(67%) 1(5%) Kim[35] 2012 Pre-treatmentassessment 98 126 17(13%) 126(100%) 81(64%) 16(20%) 45(36%) 1(2%) Fiaschetti[45] 2012 Various 60 84 9(11%) 84(100%) 43(51%) 7(16%) 41(49%) 2(5%)

Total 2239 606(37%) 2149(96%) 1301(61%) 439(34%) 848(39%) 144(17%)

Table2 DistributionofMRI-guidedvacuum-assistedbiopsiesbymorphologyandenhancementkinetics. Authors

references

Year No.of lesions

BI-RADS3 BI-RADS4 BI-RADS5 Focus CE-mass CEwithouta mass

Progressive Plateau Washout

Liberman[25] 2005 112 3(2.7%) 61(54.5%) 48(42.9%) Lehman[21] 2005 38 24(66.7%) 14(33.3%) Gebauer[30] 2006 42 22(52.4%) 18(42.9%) 2(4.8%) 28(66.7%) 14(33.3%) Lee[29] 2007 342 21(6.1%) 319(93.3%) 2(0.6%) 7(2.1%) 167(48.8%) 168(49.1%) Mahoney[32] 2008 55 6(10.9%) 30(54.5%) 19(34.5%) 17(30.9%) 15(27.3%) 23(41.8%) Hauth[31] 2008 34 7(20.6%) 19(55.9%) 8(23.5%) 23(67.6%) 11(32.4%) Han[23] 2008 150 21(14%) 61(40.7%) 68(45.3%) 66(44%) 36(24%) 17(11%) Li[61] 2009 177 98(55.4%) 79(44.6%) DeMartini[21] 2009 167 30(18%) 84(50.3%) 53(31.7%) Malhaire[33] 2010 72 1(1.4%) 32(44.4%) 39(54.2%) Crystal[34] 2011 26 8(30.8%) 18(69.2%) 14(53.8%) 10(38.5%) 2(7.7%) Zebic[62] 2012 14 2(14.3%) 8(57.1%) 4(28.6%) 5(35.7%) 9(64.3%) 1(7.1%) 6(42.9%) 7(50%) An[63] 2013 15 14(93.3%) 1(6.7%) 13(86.7%) 2(13.3%) 1(6.7%) 8(53.3%) 6(40%)

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MRI CE

Targeted examinaons

Concordant abnormality

Benign appearance on standard assessment

and MRI + low risk context

Repeat MRI at 6 months

Suspicious appearance on standard assessment and MRI

+ high risk context

Ultrasound guided core biopsy or stereotacc vacuum assisted biopsy

Histological result

Benign

Repeat biopsy or surgery

Borderline or malignant

Surgery

No concordant abnormality

Benign MRI appearance + low risk context Suspicious MRI

appearance or high risk context

MRI guided vacuum assisted biopsy

Good

targeng Poor targeng

Repeat MRI at 6 months

CE not found

Early repeat MRI (< 6 months)

Very suspicious discordant imaging

appearance

Figure1. DecisionalgorithmforthemanagementofanadditionalCEfoundonMRI.

Practical

conditions

Training

recommendations

MRI-guided biopsies should only be carried out in experi-encedbreast centers[50].The team musthave sufﬁcient

andregularexperienceinbreastMRI andvacuum-assisted

biopsy(over50proceduresannually)[50,64,71].

Inaddition,traininginMRI-guidedvacuum-assisted

biop-sieswithhistologicalconﬁrmationunderthesupervisionof

aspecialistisrequiredbeforeapractitionercanworkalone.

TheinitialtraininginvolvesthreeproceduresinFrance(as

accesstoMRIisstilllimited)[50,69]but15proceduresare

requiredaccordingtotheEuropeanguidelines[71].

Ten procedures per site per year are then sufﬁcient

[50,64,69,71].

Contra-indications

The contra-indications are those of MRI (claustrophobia, pacemaker,etc.),contrastmediuminjections(severerenal impairment, allergy) and biopsies (reduced coagulation, allergy to anesthetic agents) although these are gener-ally relativeand can be managed. Antiaggregants with a

cyclo-oxygenaseinhibitor (Aspirine®₎_or _adenosine

diphos-phatereceptorinhibitors(Plavix®_,_Ticlid®_,_Eﬁent®₎_can_be

continued[69—75].Aninitialconsultationwitha

cardiolo-gistoranesthetistinpatientsonvitaminKantagonistscanbe

usedtoconsiderpossiblyswitchingtolowmolecularweight

heparin,otherwisethedecisionisbasedontheInternational

normalizedratio([INR],derivedfromtheprothrombintime)

ontheunderstandingthattheriskofbleedingislowbelow

2andhighabove3[75,76].

One-passenblocexcisionwithradiofrequency(Intact®₎

cannot beusedbecause ofinterference withthe

electro-magneticwave.

Technique

Equipment

Magnet

ThebiopsyisgenerallytakeninaclosedMRIwithan

aver-age ﬁeld of 1 to 1.5T [11,13,25,27,28,58,60,63]. It can

becarriedoutin ahighﬁeld(3T)[63,67,77—80]in which

the sensitivity of detecting the cancer is greater for the

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increased:usinga14Gneedlethesignalvacuumis4mmat 1.5T[82]and9.5mmat3T[77].

Open machinesprovideeasieraccesstothebreastand

real time monitoring of insertion of the cannula. Few of

theseinstrumentsareavailablehoweverandtheygenerally

use a low ﬁeld(0.2—0.5T), which does not provide

sufﬁ-cientqualityimaging[83],althoughthisisstillapossibility

[84—86].

Samples are therefore takenoutside of the magnet to

avoidimagedistortionfromtheneedle[87]andtohave

suf-ﬁcient space.Interimchecks aremadein thetunnelwith

non-magnetic materials (introducer, clip, etc.) to reduce

risksandartefacts.

Inmoregeneralterms,non-magneticmaterialsshouldbe

usedinpreference(forceps,etc.)andferromagnetic

mate-rials(scalpel,needles,gun, etc.)mustneverbeput down

ontheirowntoavoidaccidentsfrommagneticattraction.

Coils

The coilsshouldifpossiblebethe sameasthoseusedfor diagnosisinordertoobtainequivalentperformance.Itmust bepossibletoaccessthebreasttotakethesamples,which assumesthatthecoilisopen.

The initial singlebreast coilsonly allowed an external approach and therefore required the practitioner topass throughtheentirebreastforinternalenhancement.

Currentdualbreastcoilsalloweitherexternal,internal orevensuperioraccess(InvivoM_,_SentinelleM_),_although_the

lateral approach should be preferred as this is the most straightforward[46](Figs.2and3),usingasofttipped

nee-dleifnecessary inordertoavoidtheriskofdamaging the

internalskintissue.

Internal accessis limitedfordeeplesionsandis

incon-venient: the contralateral breastlies ona board and the

radiologist works from beneath in a tunnel,when a

non-magneticlampmaybeveryuseful[46](Fig.4).

MRIimages

Initialandthendynamicimagesarepreferablytakenin high-resolutionT1weighted3DFSechogradientmode[48].The

acquisition may be taken through axialsections although

resolutionisoftenbetterinsagittalsections[46].

The maximum dose (0.2mL/kg) or a half dose is

injected depending on whether or not a repeat end of

procedure injection is planned. Unlike other countries

[13,27,31,32,88],in France[46,50],thevariousgroups do

Figure2. DiagramshowingaccesstoaninternalCEviaalateral (blue)andinternal(red)approach.

notadministerafurtherinjectioninordertoavoidriskof saturatingormissingthetarget(smallorpoorlyvascularized targets).

Theinjectionrateis2—3mL/sandthecontrastmedium isthenwashedoutwith20mLofserum.

Intheinterimviews,rapidT1spinecho(TSE)[50]images

arepreferableinordertoreduceneedleartefacts[58].The

CEis often poorlyvisible, in which case anatomical

land-markshavetobeused.

The principle used is thatthe same image is taken on

fouroccasions:beforebiopsy(target identiﬁcation),after

positioningaguide(checkingcorrectpositionofthebiopsy

system),aftertakingthebiopsy(conﬁrmingthatthebiopsy

cavityisconsistentwiththetarget)andafterpositioningthe

clip(checkingthecorrectpositionofthemarker)(Fig.5).

Guidingsystem

Hand to screen guidance can be used for identiﬁcations [84,89—91]butnotforbiopsies,asitisnotsufﬁciently pre-cise.

The guidancesystems,initiallyincorporatedintoa

sin-glebreastdedicatedinterventionalcoil[83,87,92],arenow

removable and can usually be incorporated into

conven-tionaldiagnosticcoils.

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Figure4. Internalapproach:GE®_coil_b:_Sentinelle_coil_(Hologic®_).

The platform may consist of a simple frame (MRI Device®_),_usually_combined_with_parallel,_ﬂexible,_vertical

orhorizontalcompressionbars(Fig.6).

Thisislinkedtoagraduatedpillarﬁxedtothecoil[77]

ortotheedgeoftheMRIbed,equippedwithrulerstoset

thexandycoordinatesandtheangulation(Figs.7and8).

Thegrid(GeneralElectric®₎_is_now_the_most_widely_used

targetsystem(Fig.3)intowhichablockguideisinserted.

This is a sterile, multi-perforated landmark cube through

whichthecannulaispassed.Regardlessoftargetingmethod,

an opaque landmark (a tube containing gadolinium [10],

aglycerincylinder [46]or vitamin Ecapsule [25])is ﬁxed

tothecompression plate.The end ofthisis positionedin

contactwiththe breastand usedasthe landmark

(refer-ence0inthethreespatialplanes),tocalculatesubsequent

targeting.This appearsasan obvioushyperintensity in an

unenhancedviewonT1weightedimages(Fig.5).

Targeting software(distances, angles),provided either

inthelandmark identiﬁcation kitor separatelydepending

onthe manufacturer, are particularlyuseful for posterior

contrastenhancement.

CAD can highlight the CE, fromthe subtraction rather

thanfromtheunenhancedimage.Thebiopsysystem used

isrecorded,then it calculatesthenecessary depthtaking

accountofthematerialsandthicknessofthecube.

Biopsysystems

Differentvacuum-assistedbiopsysystemsareused: • Atec® _9G_(Hologic_Inc,_Bedford,_MA)_{[11,13,23,25,26,29,}

34,63,93,94];

• Vacora®_10G_(Bard_Biopsy_{Systems,Tempe,}_AZ)_[23,28,30,

31,33,57,59,60,88,95];

• Senorx® _10G_(Bard_Biopsy_{Systems,Tempe,}_AZ)_[32,46]_;

• Mammotome®_11G_(Devicor_Medical_Products,_Cincinnati,

OH)[12,27,96—99].

These systems have been extensively described

previ-ously[100—102]andhavebeenadaptedtoMRIwithspeciﬁc

4m cabling and vacuum tubing allowing the pump to sit

externaltotheFaradaycage.Particularly,longprobeswith

orwithout asofttipandintroductionkits comprisingofa

plasticcannulaandtwostyli(non-ferromagneticmetal)are

used(Fig.9).

Large diameter cannulae are preferable, with a

mini-mumrequirementof11G[50],althoughaccordingtoFischer

similarresultscanbeobtainedwith9and10Gcannulae.

Anintroducerisroutinelyusedforinsertion(Fig.5).

Withcoaxialguns,thesamplesreturnthroughthe

can-nulaandarerecoveredoutsideofthebreast(Mammotome®₎

orarestoredinasmallposteriorcontainer(Atec®_,_Senorx®_,

Mammotome®_Revolve)₍_Fig.₁₀_).

Vacora®_is_a_compact,_easily_{transportable}_system_and_is

not coaxial. It does not have an integral system for

sam-plecollectionmeaningthatthecannulahastoberemoved

foreachsample(Fig.11).Thiscausesmoredifﬁcultyfrom

blood [31] andair andit is essential touse asupportfor

the gun inordertoreduce the riskof displacingthe

can-nula.Thevacuum aspirateis reportedtobelesspowerful

andthesamplingprocessslower(69vs39minutes).Coaxial

systemsarereportedtobeabletobiopsysmallerlesions(10

vs19mm),fasterandwithgreaterconﬁdence[103].

Asthesevariousgunsarenon-magnetic(Vacora®_less_than

theothers),theyarenotattractedbythemagnetalthough

interference withtheiroperation doesoccur iftheycome

tooclosetothemagnet.

The

different

stages

[12,13]

Preliminarystage:positioningandimmobilization

Thepatientispositionedonhersidewithherheadturned totheoppositeside andherarmalong herbodyorabove herheadandavenousline withlongconnection tubingin place(Fig.12).

Thebreastiswedgedinthesurfacecoilandtheguiding

systemissetupfromthebeginning.Theguidemarkis

pos-itionedincontactwiththeskinascloseaspossibletothe

projectionoftheCEifnoCADsystemisbeingused[46],or

furtherawayinordertoavoidhindranceifoneisbeingused

[28].

Thebreastis heldbetween thegrid andan often-solid

plate. Modest compression is used to avoid masking the

enhancements[83,104]andtoreducetheaccordioneffect

(decompressionofthebreastmaycausedisplacementofa

cliporlandmarksuture).

Accessibilityof thepresumed siteof thelesion isthen

checked andpositioned in the effective grid compression

area.

Stage1:targeting

The patient is brought into the magnet and an initial enhancedimageistakentofindtheCEandlocateitagainst theguidemarker(thiscanbeidentifiedbythepresenceof siliconeorparaffinwhichappearsasaT1weighted hyper-intensityonanunenhancedimage)(Fig.5a,b,e).

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Figure5. Patientwithprovenleft breastrecurrence referredfor strategicbiopsyofnon-masscontrastenhancementlocatedatthe junctionoftheinternalquadrantsoftherightbreast.ThepatientispositionedforaninternalapproachandMRIimagesaretakeninsagittal sections.SagittalreconstructionMIP:a:stage1:targetidentiﬁcation:theenhancementislocatedimmediatelybehindthegrid;b:new stage1:identiﬁcationofthetarget;afterremovalofthecoilfoamstheCEprojectsontothegridandbecomesaccessible;c:stage2: positioninganintroducer;thisislocatedontheposteriorsurfaceofthecontrastenhancement;d:stage5:postbiopsyphase,visualization ofahematomaofapproximatelyacentimeterinsizearoundtheintroducerinplaceoftheinitialenhancement.AxialreconstructionMPR:

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Figure6. Guidingsystem:a:Device® MRIsystem.Theintroducerisinsituwithitssiliconesheath;b:Devicor® system.Theceramic introducerisequippedwithawindowopeningontothesamplingarea.

Figure7. Supportsforthebiopsygun:a:withtheDevicor®,_system_the_dedicated_gun_is_ﬁxed_to_the_coil;_b:_the_Siemens®_system,_this

occupiesmorespaceandisusedasthesupportfortheguide.Itisﬁxedtotheexaminationbed.

Figure8. Sentinellecoil(Hologic®₎_with_its_grid_and_angulation_system:_a:_frontal_view;_b:_lateral_view.

Distancesaremeasured manuallyorbysoftwareinthe 3spatialplanesbetweenthisreferencepoint(‘‘zero’’)and theabnormalCE.

Stage2:positioningtheintroducer

Afterdisinfectionandlocalanesthesia,askinincisionmay berequireddependingontheshapeoftheendofthe can-nula.

Thesterilecubeis theninsertedintothegrid,possibly after initiallytapering theintroducer onthe cube, which allowstheskinincisiontobefoundmoreeasily[46](Fig.13).

Depthisthenadjustedtakingaccountofthethicknessof

thecubeandadding20mmforSenorx®_,₁₀_mm_for_Vacora®_,

butnothingforMammotome® _[46]_.

Onceinplacethemetalsheathisreplacedwithasilicone

sheathorwiththepositionmarker.Thepatientisreturned

e:stage1;f:stage2;g:stage2;h:stage5;i:stage5:thisotherimage(axialT2*)maybeusefultoviewtheclipwhichisnotalways clearlyvisibleontheconventionalT1weightedechogradientimages.Themetalmarkerappearsasapronouncedhypointensityinsidethe hematoma,whichisapronouncedhyperintensity(asveryrecent).Thesefourstagesofthebiopsyinsagittalandaxialimagesshouldmake upthetwoﬁlmsprovidedinthesummary.

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Figure9. FittingthematerialstotheMRIguide:a:thevacuumcablingandtubingareextendedtokeepthevacuumaspirationpump (Devicor®)outsideoftheFaradaycage;b:Bard® introducingkitwithacannulaandtwosheaths(metalandsilicone);c:theroundedend ofthecannulaavoidsdamagingthecoveringskin.

Figure10. Differentmeansofrecoveringsamples;a:withtheVacora®,non-coaxialsystem,thecannulaiswithdrawnfromthebreastto recovereachsample;b:withtheMammotome®,thesamplesarerecoveredastheprocedureprogressesthroughawindowlocatedoutside ofthebreastandinfrontofthegun;c:withtheEncor®_,_the_specimens_are_stored_in_a_container_located_at_the_back_of_the_gun.

insidethemagnetandarapidimageisthentakentocheck thecorrectpositionoftheintroducer.Thebiopsywindowis visibleontheMammotome® _cannula₍_Fig.₅_c,_f,_g,_6a).

Stage3:biopsy

The introducer is replaced by the cannula and then a series of samples is taken (Fig.11). The number of

sam-ples depends onthe size of the lesion, cannula diameter

andqualityoftargeting.

Withan11G cannula,theminimumnumberofsamples

requiredis24accordingtotheEuropeanguideline[64]and

12accordingtotheHAS[50],oranequivalentvolumewhen

alargergaugecannulaisused[62,64].

Thenumberofsamplesreportedintheliteratureranges

from2 to75[23,25,28,31,33,62,96,105]withamedian of

12[13,25,31,33,60,62,105].

Thesamplesarethenplacedinabottleandsenttothe

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Figure11. LargecorebiopsywiththeVacora®_10G,_{miniaturized,}

non-coaxialsystem.

Figure 12. Patient positioning on their side with the breast wedgedinanopencoilandthestereotacticguidingsystem pos-itionedfromthebeginningforalateralapproach.

details,whichareabsolutelyessentialforMRI-guided biop-sies.Thespecimensareﬁxedandthenatleastthreesections areprepared.Theymustbereadbyanexperiencedbreast histologist[33,34,50].

Stage4:labelingthesite

A clipis routinely positioned[13,25,26,33,46,50,54,60]as

thisis theonlylandmark,whichcan beusedtoguideany

subsequentrevisionsurgery.

It may not be used if the patient refuses [26], if

positioning has failed or if one is not applied routinely

[13,26,33,34,88].

Itispositionedthroughthecannulabeforethecannulais

removedorafterthecheckimage,throughtheintroducer.

Stage5:endofprocedurecheckimage

The patient is repositioned in thetunnel for a lastcheck sequence,whichisessential[50].Thisisusedtodetermine

whether the contrast uptake has reduced or disappeared

[27,87], although it is often sufﬁcient to check that the

biopsy area is correctly centered on the initial CE (by

comparingwiththepre-biopsyimage) andthattheclip is

correctlypositioned(Fig.5d,h,i).

This sequence is carried out with [13,27,31,32,88] or

without[46,50]contrastenhancement.

Iftheresultisnotsatisfactoryfurthersamplesshouldbe

takenorthelesionretargeted.

Attheendoftheprocedure,thepatientisremovedfrom

thetunnel,placedﬂatonherbackandmanualcompression

is applied followedby a compressive dressing.Monitoring

forhalf anhouraftertheprocedureisgenerallysufﬁcient

[50].

ThesedifferentstagesareillustratedinFig.14.

Duration

Theaverage timespentintheMRIisapproximately1hour

[50,63,87,106]: 20 [11] to 70minutes [27,33,98]. This is

increased by 30 to50% [11,25,50,98] when two sites are

biopsied.

Figure13. Insertionoftheintroducer:a,b:thesheathisinsertedintothecube;c:thesheathassembledontothecubepassesthrough theskinandtheskinisthenﬁxedtothegrid.

(11)

Figure14. Thisisa53-year-oldpatientwhohadintramammarysiliconeinjections20yearsearlierandwasthentreatedforrightbreast cancer2yearsago:a,b:mammographyandultrasoundaredifﬁculttointerpretbecauseofthediffusesiliconomas;c:monitoringistherefore mostlybasedonMRIwhichshowedarelativelyunsuspiciousCEinthecontralateral,supero-externalquadrantsuggestiveofanintramammary lymphnode.AsecondlookexaminationwasnegativeandarepeatMRIwascarriedout6monthslater.Thisshowedanincreaseinsizeof

(12)

Figure15. Non-magnetictrolleyallowingpreandpostbiopsy pro-cedurestobecarriedout,outsideoftheroomandthereforelimiting thetimeintheMRIroom.

AccordingtoNorozian[106],thelengthoftheprocedure

dependsonthenumberofimagesandchecksinthetunnel,

whetherornotanassistantispresentandproximitytothe

nipple,asthisisreportedtobeindependentofpatientage,

sizeofthebreastandtypeorsizeofenhancement.

The MRI room occupation time can be reduced with

prior planning the positioning and venous access before

the procedure [106] and by using a coaxial system [33]

or even a second non-magnetic trolley. This enables the

pre-procedure(positioningthe materials andpatient)and

post-procedureactivities(removingthetrocar,compression

anddressing)tobecarriedoutoutsideoftheMRIroom.The

occupationtimeis thus reduced byapproximatelya third

(Fig.15)to35—39minutes[11,13,46,62].

Some practitioners even take the samples outside of

theroom,takingadvantageofthisapproachtotakemore

samples (>18) to reduce underestimation, although they

positiontheclipatthebeginningoftheprocedureanddo

nottakeapost-biopsycheckimage.

Documents

to

be

given

out

at

the

end

of

the

procedure

The patientleaves withan informationformand instruc-tions,a provisional reportand images.This reportshould describe[69]:

• theclinicalcontextofthebiopsy;

• thelesion(appearance,withBI-RADSclassiﬁcation,size

andsite);

• theapproachroute;

• thematerialsused;

• thesamples(number,diameter)[76];

• traceabilityofthematerialsused(cannula,clip).

Images should be provided if possible in all the three

spatialplanes.

Foursummaryimagesineachofthetwoplanes(axialand

sagittal)areessential,showingtheinitialCE,introducerin

place,afterbiopsyandtheclipcheck[46,50](Fig.5).

Two orthogonal mammography ﬁlms of the breast

are taken to check the correct positioning of the clip

[46,50,64,69],eitherimmediatelyorlatertoavoidmoving

it.

It is correctly deployed in 93 to 100% of cases

[25,26,60,62]andfailuresareduetonon-deploymentinto

asuperﬁciallesion,bleedingortechnicalerror[25,26].

Clip positioning was correct (<10mm) in 79% of cases

reported by Malhaire[68] and 96% reported by Siegmann

[107],withanaveragedistanceof4.5mm[107].Siegmann

[107]didnotﬁndanysecondarydriftandvisualizedtheclip

correctlybyultrasoundin93.1%ofcasesandbyMRIin86.2%.

Despitearepresentativesample beingtaken,incorrect

clip positioningmay occasionallyresultin repeat biopsies

needingtobeperformed[61].

Limitations,

difﬁculties

and

tips

If MRI is contraindicated or technically impossible, the optionofCT-guidedbiopsyshouldbeconsidered[108].

Strictprolongedimmobilizationwiththepatientonher

side requiresgoodpatientcooperationfrom50% ofwhom

ﬁndthepositionuncomfortable[88].

Ten to 25% of procedures [27,57,58,97,109,110]

can-not be performed, usually because the CE is not found

(2 to17%)[23,25,27,30,31,33,38,57,63,80,97,98,110,111],

although occasionally because of obesity [57,109,110] or

lackofaccessibility[33,57,109].

TheCEmaynotbeseenbecause:

• ithasdisappearedbecauseofexcessivecompression (in

which case a further image should be taken with less

compressionofthebreast)oriftheinitialMRIwascarried

outatthewrongtimeofthemenstrualcycle[97,111];

• it is no longer clearly identiﬁable because of masking

oftheenhancement,smallsize(<5mm),post-treatment

changesorlimitedoperatorexperience[46].

Thiseffectisascommonwithhighﬁeldsaswithaverage

ﬁelds[80].

theCEandguidedultrasoundremained negative.Thedecisionwasthenmade tocarryoutMRI-guidedvacuum-assistedbiopsy;d:the examinationwasperformedinasagittalacquisitionwithagridsystem.Theskinlandmarkwaslocatedonthelateralsections;e:theCE wasseenagainandwasmoreintenseandposterior.Themousepointerwasplacedontheenhancementasalandmarkandtheimages scrolledthroughuntilthelandmarkcubewasseen,placingtheimprintofthegridontheskinonthesection;f:thepositionoftheCEis thentransposedtoadiagramreproducingthelateralshapeofthebreast(inthiscasetheCEiscoloredblueandtheskinlandmarkred). Thisavoidserrorsmovingfromthepositionofthediagnosticimages(sagittalsectionsshownuprightontheconsolescreen/ontheleft),to thebiopsyposition(patientlyingdownonherside/ontheright).Thexandycoordinatesarethencalculatedonthegrid.g.toestablish thedepthz.Thesectionpositions,CEandguidemark,canbesubtractedorthedistancebetweentheCEandskinmeasureddirectlyon areformattedimagetakingcaretopositionthemarkeronthetheoreticalexternaloutlineoftheskin;h:theintroducerispositioned, poorlyseeninthisaxialsection,followedbyadozensamplesbeingtaken(9Gcaliber);i:aclipispositionedafterthecannulaisremoved. ThecheckimageshowshemorrhagicchangeshinderinganalysisoftheresidualCE;j:butthehistologicalresultisbenignandinagreement showingalymphnodecontainingtumor.

(13)

Itisthenpossibletotrytoidentifyitusingneighboring anatomicalstructuresontheinitialdiagnosticMRI.

Ifithasnot,however,been possibletotakebiopsies,a repeatMRIwithout compression isneeded within24hours

[46] or even in the following months [97,111]. Viehweg

[97]howeveronlyproposedthisrepeatinperi-menopausal

womenor thoserecentlystartedonHRT.This maynotbe

sufﬁcient,aswhilstthemalignancyratefortheseCEwhich

havedisappearedonthedayofbiopsyandarereviewed

sub-sequentlywaszeroaccordingtoHan[23]andAn[63],the

correspondingﬁgurewas2%forThomassin[46]and10%for

Heﬂer[111].

Liketheotherguidingmethods,retro-alveolaror

super-ﬁciallesions,smallbreastsorprostheticimplants(Fig.10)

maycomplicate theprocedure (compression, accessibility

orcomplication)[58].

AccordingtoMalhaire,2%ofprocedureswere

inaccessi-ble[33].

Cushions can be added for smallbreasts or the breast

swollen artiﬁcially with a ‘‘wonder bra’’ type bandage

(elastoplast applied horizontally or vertically), using soft

tippedcannulaeandasamplingchamberreducer[46,47].

The lateralapproach shouldbe usedin preference for

deeplesionsinordernottobeimpededbythesternum[46].

Thepatientsarmcanbepositionedalongherbodyandthe

foamremovedfromthecoilthetablecushionremovedand

theoppositesideofthepatient’sbodyraised tobringthe

breastdownintothecoil[46].

Ifthepectoralmuscleisprominentanattemptshouldbe

madetoﬂattenitbychangingthepositionofthearm(along

thebodyorabovethehead).

If the entrance point is located outside of the grid,

the procedure can be performed unguided (free-hand

technique) although a horizontal path is not guaranteed

[47,67,84,89,90].

Some coils (SentinelleM₎ _allow _the _grid _to _be _shifted,

maintainingaparallelapproachtothewall.Otherssuggest

thatthecannulacanbeinsertedatanangle,althoughthis

carriesariskofwalldamage(pneumothorax,etc.)(Fig.8).

TablecushionscanbeaddedforanteriorCEsorthebreast

thicknessincreasedwitha‘‘wonderbra’’bandage.

Ifaprostheticimplantispresent,thisshouldbepushed

asideandthecannulapositionedontheanteriorsurfaceof

theCE:

• theprocedureshouldbeperformedrelativelysoonafter

the gadolinium injection (<15minutes) as malignant

lesions ‘‘wash out’’ [46] and the neighboring tissues

enhance[47,83].Thebloodhyperintensitycontributesto

maskingtheCE;

• patientmagneticsusceptibilityandmagneticﬁeld

distort-ionsduetothecoilandmetalneedlesmaycauseballistic

approximationsbecauseofneedledrift[55]orthelesion

beingpushed aside[83].Largecaliberneedlesalso

cre-ateasignalvoidproportionaltotheirdiameterwhichis

reducedwithMRIcompatibleneedles[55]andmaymask

theenhancementand/ortipoftheneedle[55,83,112].

Theclipcausesamagneticsusceptibilityartefact,which

isseenontheﬁnalimages.Airinsidethebiopsycavityalso

generatesasignalvoid,whichcancauseidentiﬁcationerrors

[47].

Asless compressionisappliedthanfor stereotaxis,the

riskofthelesionbeingpushedasideisgreaterbutthe

accor-dioneffectandthereforetheriskofincorrectlypositioning

theclipisless.

ElKhouli[113]foundanaverageoverallballisticerrorin

thespace of4.4mm onamodel and 5.7mm onpatients,

independentlyofoperatorifaprotocol ispresentand

fol-lowedandconcludedthatCEareaccessibleupto5—6mm.

In order to improve the reliability of MRI-guided

biop-sies some therefore recommend preferentially biopsying

enhancementsofover5mm [8,114],oreven10mm[4,8],

giventhat contrastenhancementofunder5mmisusually

benign [24,115]. Perlet [27], however, felt that

vacuum-assistedbiopsyperformedwellandwasparticularlyuseful

forsmalllesionsasthelargeronesweregenerallyvisibleon

ultrasound.

Severalpitfallslimitthediagnosticconﬁdencecompared

towhatisachievedwithmammographyorultrasoundguided

biopsies[46,47,58]:

• thereisnocheckwithacannulainsitu,andevenlessin

realtime;

• thesamplingradiographsareofnouseiftheycontainno

calciumorﬁbroussignal;

• pathologistshavenocalciﬁedornodularlesion.

Management

of

the

result

Technical

success

AccordingtoCrystal[34],thedistancebetweenthecannula

andCEmustnotbemorethan3mm.

Successisassessedparticularlyhoweverfromthe

reduc-tionordisappearanceoftheCE.

Perlet[27] andthenTosaki [116]referred tosuccessif

theenhancementwasreducedbyatleast50%.

AccordingtoHauth[31]andGhate[60],apartial

unquan-tiﬁedreductionis sufﬁcient whereasmost authors donot

reporttheircriteriaforsuccess.

The assessment is hindered by bleeding in 9 to 38%

of cases [60,63,87], air, the anesthetic agent and

move-ments[47,57,117].Inthissituation,Perlet[27]carriesout

arepeat MRI 2 to 4daysafter the procedure. Hauth [31]

even routinely replaces the check sequence at the end

of the procedure with an MRI 24hours later in order to

optimallyassess whether the procedure is representative

andusesthistoexplainherlowersuccess ratethanother

series.

AccordingtoPerlet,successdoesnotdependonthesize

oftheCEortheexperienceoftheradiologist[27].

Malhaire[33]howeverdescribedfailuresandmissed

can-cersduringtheinitiallearningperiod.

Enhancementsof4and100mm arereportedinthe

lit-eraturewith an average of 10mm [11,13,25,26,33,60,63,

105,113]. These disappeared in 33.1% of cases (4—81%),

reduced in 59.6% (18—87%) and were unchanged in 7.3%

(0—30%)[25,27,29,31,60,87,88,116,118](Table3).

Complete excision rates for the radiological signal are

similartothoseachievedwithstereotacticbiopsies(≈38%)

[102,119]andlessthanthosewithultrasound-guided

(14)

Table3 Assessmentofsuccessofvacuum-assistedbiopsybasedonthechangeinCE.

Authorsreferences Year Nochange(%) Partialresolution(%) Completelydisappeared(%)

Heywang[87] 2001 1 87 12 Liberman[25] 2005 4 66 29 Ghate[60] 2006 30 65 5 Perlet[27] 2006 4 Lee[29] 2007 1 69 30 Tozaki*[116] 2007 0 40 60 Hauth[31] 2008 13.8 72.4 13.8 Perretta[88] 2008 4 Ferré[118] 2011 1 18 81 An[63] 2013 0 87.5 12.5 Mean 6.4 63.1 25.1

*Onlyﬁvepatients.

The average size of the CE, which completely disap-pearedhoweverwas13.9mmaccordingtoFerré[118].

Failuresareuncommon(0to14%)[11—13,25—27,30—33,

46,60,62,96—99,118,120,121]andareduetoinadequateor

discordantsamples[25—27,58,87,110].

These may be due to patient reactions (malaise or

anxiety) [25—27], technical difﬁculty with the materials

(cannulaor table), patient(accessibility, breast toothin)

[26,27,60],oroperator[27],orbleeding[46].

AccordingImschweiler[121],therefore,thesuccessrate

is similarto that achieved withstereotactic biopsies and

lower than that achieved with ultrasound-guided

proce-dures.

Histological

result

Thedistributionofhistologicalresultsvariesgreatly depend-ingonrecruitmentforbreastMRI.Benignresultsarefound

in18to74%ofcases[11,13,25—28,60,87,89,98,99],

border-linein1to21%[11,13,25,26,28,60,87,97—99]andmalignant

in5to61%[11—13,25—28,46,60,87,96—99,120].

The PPV ranges from 5 to 100%, [13,25—27,

30,31,33,38,60,63,96,98,121] and the NPV is over 93%

[27,38,121].

IftheindicationsforMRIarecorrectlyfollowed,however,

themalignancyrateisover20%,whichjustiﬁesthesamples

beingtaken(Table4).

AccordingtoGebauer[30],themalignancyratewas4.5%

(1/22)for BI-RADS3,44.4%(8/18) forBI-RADS4and100%

(2/2)forBI-RADS5.

Thisisreportedtobehigherindiagnosticcomparedto

screening examinations(personal history, highrisk) (32 vs

12%)[23,122] andforCE withamassappearanceor wash

out[62,122].

Han[23],however,reportedthatthisratedidnotdepend

oneitherthetimeorthekineticsoftheCE.

Table4 Context inwhichtheMRI-guidedvacuum-assisted biopsieswereperformed: distributionbyseriesand corre-spondingmalignancyrate(inbrackets).

Authors [references] Year Pre-treatment assessment(%) Post-treatment followup(%)

Highriskfamily (%) Suspicious mammography Otherindications (%) Abnormalityon oneview(%) Liberman[25] 2005 23(27) 9(25) 46(19) 21(45) Lehman[11] 2005 61 24 15 Orel[26] 2006 54 15.3 30.7 Perlet[27] 2006 8(36) 29(32) 11.4(27) 21.9(20) 29.7 Plantade[28] 2006 40(50) 10(100) 50(40) Lee[29] 2007 31 10 34 24 Gebauer[30] 2007 29.4 2.4 68.2 Han[23] 2008 41(36) 16(23) 13(28) 30 Hauth[31] 2008 18.2 39.4 9.1 33.3 Mahoney[32] 2008 21 38 41 DeMartini[21] 2009 26 10 22 16 26 Malhaire[33] 2010 13 32 32 25 Crystal[34] 2011 8 39 38 15 ():malignancyrate.

(15)

Mass CE are more often malignant [46] and are

usually due to inﬁltrating carcinoma (64%) [22,25]

whereas non-mass CE are due particularly to DCIS (80%)

[25].

Discordances

Therearetwotypesofdiscordance:

• site:thebiopsyareaislocateddistanttotheCE; • histology:theresultis unexpectedinlightoftheCE

BI-RADSappearance.

Concordant benign samplesmake up0 to12% of cases

[11,13,23,25,26,28—30,32,60,61,88,96,123]withameanof

5.3% [23,25,26,29,30,32,33,118] and the malignancy rate

ranges from0 [43,65] to 100% [26,28,30]with a meanof

44.5%[23,25,26,29,30,32,33,118](Table5).

These results aresimilartostereotacticor

ultrasound-guidedbiopsies.

In Lee’sstudy[122],theCEwasreducedin71% of

dis-cordantcasesalthoughthemalignancyrateinthissituation

was27%. This highlightsthe importanceof checking

radi-ological and histologicalconcordance, [25,26,69,123] and

justiﬁesafurtherbiopsy(percutaneousor surgical)of

dis-cordances [123], ratherthan a repeat MRI after6months

[61].

Similarly,insufﬁcientsamplesshouldberepeated.

Final

report

and

conclusion

(

Fig.

1 )

Once thehistopathological diagnosishas beenreceived, a summaryoftheresults,theirconcordanceandfuture man-agementshouldbeincludedinthereport[69].

For concordant benign lesions authors recommend

a repeat routine MRI in 6 to 12months [10,11,25,

58,60,63,64,87],orevenin3to6monthsaccordingtothe

HASworkinggroup[46,50],bearinginmindthelimitations

ofthisfollow-up[61].

Revisionsurgeryisrequiredforcarcinomasorborderline

lesions[27,34,50].

Finally,allcases[33,64]oratleastambiguouscases[69]

shouldbediscussedintheMDT.

Inthissituation,mostauthorsdonotreportanymissed

casesofcancer[25,27,31,32,87,88,95].

TheHASworkinggroup[50],however,estimatedamissed

diagnosis rate of 1—2% compared to 2.3% according to Li

[61],whichisstillacceptable.

Underestimations

Theseareduetoundergradingofthehistologicallesion(ADH vsDCIS,borderlineorDCISvsinﬁltratingcarcinoma)andare reportedoverall tooccur in 4 to 19% of cases [23,38,96]

(Table6).

Figures range from 11 to 50% for all borderline

lesions[23,25,26,33,34,46,60,106,122],withameanof28%

[23,33,34,46,106,122].

Brennan[79]publishedalargeseriesof1487MRI-guided

vacuum-assistedbiopsies,witha5%papillomarate.

Quasi-routinesurgicalrevision(67/75)foundunderestimationsof

5%for papillomaswithout atypiaand9%,whenatypia was

present.Thisisrelativelysimilartoultrasound-guided

pro-cedures[129].

ADH represents 4 to 11% of biopsies and has an

average underestimation rate of 32.4% (13—100%)

[11,26,27,32—34,60,88,94,95,118] (Table 7), which is

twicethatofstereotacticprocedures[113,121].

Nopredictiveindicatorshavebeen identiﬁedtoreduce

the underestimation rate for ADH [94] or for borderline

lesionsmoregenerally[34].

Underestimations for DCIS range from 0 to 25%,

with an average of 10.3% [11,23,25—27,29,33,88,95,99]

(Table8),whichisrelativelysimilartostereotacticbiopsies

[27,119,129]or ultrasound-guidedbiopsies[100].Lee [29]

foundasigniﬁcant increaseinunderestimationswhen

pos-sibleconcomitantmicroinﬁltrationwaspresent(17vs80%),

althoughfoundnootherpredictiveindicators(size,excision,

etc.).

Likethestereotacticbiopsies,underestimationsofADH

appearthereforetooccurmorecommonlythanwithDCIS.

Complete

excision

of

the

carcinoma

Completepercutaneousexcisionofthecarcinomahasbeen reported in 0 to 25% of cases with an average of 13% [11,19,23,25,27,29,31,33,46,88,105,118](Table9).

AccordingtoPerlet[27],thisonlyinvolvedlesionsunder

acentimeterinsize.

Table5 Discordancefrequencieswiththeirassociatedmalignancyrates.

Authors[references] Year Numberoflesions Discordance Numberofsurgicalcases Cancersandsurgery

Liberman[25] 2005 112 9(9%) 8 4(50%) Orel[26] 2006 85 2(2.4%) 2 2(100%) Lee[29] 2007 342 24(7%) 20 6(30%) Mahoney[32] 2008 55 3(11%) 2 0(0%) Gebauer[30] 2008 42 1(2.4%) 1 1(100%) Han[23] 2008 90 1(0.9%) 1 0(0%) Malhaire[33] 2010 72 3(4%) 3 2(66.7%) Ferré[118] 2011 146 7(4.8%) 7 5(71.4%) Total 944 50(5.3%) 44 20(44.5%)

(16)

Table6 DistributionandresultsofMRI-guidedcoreandvacuum-assistedbiopsypunctures. Typeof procedure Authorsand references Needle diameter Gauge Year Numberof lesions/patients

Size Benign Borderline

Pre-operative localization Kuhl[104] 1997 97/66 44(45%) Daniel[89] 20/21 1998 19/17 0.9(0.3—6) 11(58%) Fischer[8] 1998 132 68(52%) 0(0%) Orel[124] 20 1999 137 1.2(0.3—7) 80(58%) Smith[59] 22 2001 16/16 11(69%) Lampe*[125] 2002 132 0.9 62(47%) Bedrosian[126] 2002 41/41 22(54%) Morris[5] 18/20 2002 101/69 1.1(0.2—8) 61(60%) 9(9%) Taourel*[127] 2002 264 169(64%) Fineneedle aspiration cytology Wald[128] 22 1996 18/16 1.8(1—3.6) 16(89%) Fischer[8] 19.5 1998 31 24(77%) 0(0%) Core Smith[59] 16 2001 25/23 20(80%) Biopsy Daniel[84] 2001 27/19 18(67%) Kuhl[82] 14 2001 78/59 1.5(0.6—3) 50(64%) Schneider[85] 14 2002 21/21 (0.5—1.7) 13(62%) Chen[10] 14 2004 35/29 1.5(0.3—7) 21(62%) 5(15%) Vacuum Viehweg[12] 11 2002 280 208(74%) Biopsy Perlet*[98] 11 2002 341 233(68%) 24(7%) Heywang[87] 11 2002 87/80 63(73%) 1(1%) Orel[120] 12 2003 9/8 5(56%) Liberman[25] 9 2005 98 1(0.4—8.5) 52(60%) 10(12%) Lehman[11] 9 2005 38/28 1.1(0.2—7) 22(58%) 2(5%) Wiehweg[97] 11 2006 97/63 62(71%) 4(5%) Perlet*[27] 11 2006 538 (0.3—2.1) 362(70%) 17(3%) Orel[26] 9 2006 95/75 1.7(0.5—10) 15(18%) 18(21%) Ghate[60] 10 2006 20/19 0.8(0.4—2) 14(74%) 4(21%) Plantade[28] 10 2006 10/10 0.8(0.4—7) 5(50%) 0(0%) Gebauer[30] 10 2006 42/32 0.9(0.3—2.3) 28(67%) 3(7%) Liberman[94] 9 2007 237 156(66%) 37(16%) Lee[29] 9 2007 373 306(82%) Tozaki[116] 11 2007 30 1.6(0.5—2.5) 4(80%) 1(20%) Perretta[88] 10 2008 47/47 0.9 28(60%) 4(8%) Han[23] 10 2008 172/154 1.5(0.4—7) 90(60%) 21(14%) Hauth[31] 10 2008 29 1.3(0.5—3.2) 20(69%) 0(0%) Mahoney[32] 10 2008 55/47 <1(—3.7) 38(69%) 7(13%) Fischer 9/10 2009 389/365 231(59%) 50(13%) Malhaire[33] 10 2010 72 1.2(0.4—7) 29(40%) 10(14%) Oxner[95] 10 2012 187/127 (0.4—1.2) 126(68%) 16(9%) Imschweiler*[121] 2013 557 283(54%) 107(20%)

Cancer Underestimation Complications Timein

minutes Success ADH DCIS 53(55%) 40(30-60) 95(98%) 8(42%) 1(5%) 64(≤90) 19(100%) 64(48%) (30-60) 127(98%) 57(42%) 134(98%) 5(31%) 3(19%) 16(100%) 70(53%) 3(2%) 127(96%) 19(46%) 41(100%)

(17)

Table6 (Continued)

Cancer Underestimation Complications Timein

minutes Success ADH DCIS 31(31%) 3(3%) 31(15-59) 101(100%) 95(36%) 259(98%) 2(11%) 42(30-80) 11(61%) 7(23%) (30-60) 28(90%) 5(20%) 0(0%) 24(96%) 9(33%) 70(55-90) 27(100%) 28(36%) 1(2%) 60(45-100) 77(99%) 8(38%) 45(40-65) 20(95%) 8(23%) 2(40%) 1(100%) 0(0%) 34(97%) 72(26%) >60 277(99%) 84(25%) (18%) 0(0%) 16(5%) (70-90) 334(98%) 22(26%) >60 86(99%) 4(44%) 9(100%) 24(28%) 2(50%) 1(11%) 6(6%) 33(17-60) 95(97%) 14(37%) 1(50%) 1(25%) 0(0%) 50(39-61) 38(100%) 19(24%) 138(27%) 5(29%) 3(4%) 27(5%) 70 517(96%) 52(61%) 2(25%) 4(24%) 0(0%) (30-60) 83(98%) 1(5%) 1(33%) 0(0%) 5(26.3%) 19(95%) 5(50%) 0(0%) 70 9(90%) 11(26%) 0(0%) 32(100%) 44(19%) 5(38%) 67(18%) 5(17%) 0(0%) 48(30-60) (100%) 15(32%) 1(25%) 1(14%) 2(4%) 47(100%) 39(26%) 5(19%) 9(31%) 4(14.3%) 65(52-87) 25(86%) 10(18%) 2(67%) 0(0%) 2(4%) 55(100%) 106(28%) (<1%) 43(17-95) 38(100%) 33(46%) 1(100%) 2(22%) 3(3%) 72(50-131) 69(96%) 44(23%) 2(13%) 0(0%) 0(0%) 137(26%) 20(19%) 38(7%) 548(98%)

():range;*:multicenterstudy.

Table7 Underestimationforatypicalductalhyperplasia.

Authorsreferences Year NumberofADH Numberofcarcinomasonsurgery Underestimation(%) Diagnosed Operated Lehman[11] 2005 2 2 1 50 Orel[26] 2006 8 8 2 25 Perlet[27] 2006 17 17 5 29 Ghate[60] 2006 2 2 1 50 Liberman[94] 2007 15 13 5 39 Perretta[88] 2008 4 4 1 25 Mahonay[32] 2008 3 3 2 67 Malhaire[33] 2010 7 1 1 100 Crystal[34] 2011 7 6 3 50 Ferré[118] 2011 9 9 3 33 Oxner[95] 2012 15 15 2 13 Total 80 71 23 32

(18)

Table8 Underestimationforductalcarcinomainsitu.

Authorsreferences Year NumberofDCIS Numberofinﬁltrating

carcinomasonsurgery Understimation (%) Diagnosed Operated Liberman[25] 2005 13 11 1 9 Lehman[11] 2005 4 4 1 25 Orel[26] 2006 17 17 4 24 Perlet[27] 2006 64 64 3 5 Lee[29] 2007 29 29 5 17 Han[23] 2008 15 10 1 10 Perretta[88] 2008 7 7 1 14 Tozaki[99] 2010 28 28 3 11 Malhaire[33] 2010 9 9 2 22 Oxner[95] 2012 25 25 0 0 Total 211 204 21 10

Table9 Frequencyofcompletepercutaneousexcisionofthemalignanttissue.

Authorsreferences Year No.ofcasesinwhichnoresidualtumourwasfoundon revisionsurgery

Ductalcarcinomainsitu Inﬁltratingcarcinoma

Lehman[11] 2005 −2/13(15.4%) Liberman[25] 2005 2/11(18.2%) 2/9(22.2%) Orel[19] 2006 4/17(25.5%) 3/30(10%) Perlet[27] 2006 13/64(20.3%) 6/74(8.1%) Lee[29] 2007 5/34(14.7%) Peretta[88] 2008 2/8(25%) Han[23] 2008 0/18(0%) 0/25(0%) Lee[105] 2008 −12/67(18%) Hauth[31] 2008 −1/9(11%) Malhaire[33] 2010 1/5(20%) 4/17(23.5%) Ferré[118] 2011 −4/45(8.9%) Thomassin[46] 2011 −0/19(0%) An[63] 2013 −1/3(33.3%) Total −57/434(13.1%)

AndLee [105]reportedthatthecompleteexcisionrate

increasedifthelesionwasunderacentimeterinsize(28vs

9%)oriftheCEcompletelydisappeared(36vs9%).

Likestereotaxis[130]orultrasound[131,132]nofactors

suchasdisappearanceoftheradiologicalﬁnding,currently

conﬁrm that no residual tumor is present, although this

couldbeuseful in considering additionallocaltreatments

suchasfocusedultrasound.

Complications

ThemorbidityofMRI-guidedvacuum-assistedbiopsyislow andrangesfrom0to6%[11,13,25—27,30,57,100].Thisisa

similarratetostereotacticproceduresandhigherthanfor

ultrasound-guidedbiopsies[121].

Complications (hematomas, malaise, skin damage) are

generallyminor[25,26,30].

Tenpercentofprocedures,however,havetobestopped

becauseofadverseeffects(heavybleeding,malaise,

hyper-ventilation,etc.)[46].

Bleedingrequiringsurgeryonlyoccursinlessthan1%of

procedures[25—27,30,33,87].

Comparison

with

other

MRI-guided

procedures

Preoperativelandmarking,aspirationsandcorebiopsiesare lessaggressiveprocedures,whichusemorereadilyavailable andlessexpensiveequipment.

Pre-operativelocalization,however,istheﬁrststageofa surgicalprocedure,whichisofdebatableutilityfora poten-tiallybenignlesion.Vacuum-assistedbiopsyisthereforean attractive alternative [4,5,8,12,20,26].Fine needle

cytol-ogy aspiration often returns insufﬁcient material for the

diagnosis[96,128].

Corebiopsiesproducedgoodresults[10,82,104,133,134]

although the needle has tobe removed for each sample.

It is reported to be faster than vacuum-assisted

biop-sies butinadequatefor lesionsunderacentimeterin size

(19)

Thesuccessratesforcore-[10,30,77,80,82,83,134,136]

and vacuum-assisted biopsies [11,25,26,62,78,98,103,137]

arereportedtobesimilar(>93%)althoughvacuum-assisted

biopsiesarereportedtohave a betterrepresentivity rate

[78](Table7).

The authorstherefore recommend that unless

unavail-able or technically impossible, vacuum-assisted biopsy be

usedinpreference[78,138,139].

Tariff

and

accessibility

MRI-guidedvacuum-assistedbiopsiesdonotcurrentlyhave anyspeciﬁccode.

Only item QEHJ006 (=percutaneous mammary gland biopsy with remnographic guidance) exists. This is MRI-guided core biopsy and carries a tariff of 76.80Euros to whichthebreastMRItariffcanbeadded.Thisis consider-ablylessthanthecostofthevacuum-assistedbiopsycannula andtheMRItimerequired.

Thisappliesevenmoretodualproceduresasthe exami-nationtimeisincreasedandtwocannulaearerecommended [50].

In order not to lose out ﬁnancially, some apply

the stereotactic vacuum-assisted biopsy tariff (QEHH002:

511.68Euros)orthetariffforadayhospitaladmission.

The reimbursementﬁle washowever submittedto the

HASin July2009 andthetechnicalassessmentreportwas

publishedinDecember2011,althoughthisprocedureisstill

notincluded inthe FrenchJoint Classiﬁcationfor Medical

Procedures.

The tariff for a vacuum-assistedbiopsy in theUSA and

Australiaisthesameregardlessoftypeofguidingused.

In addition, despite the recent approvals for MRI, in

France the numbers of instruments available are still

far below those in its European neighbours, particularly

since MRI screening for at risk women has been

intro-duced.

Access tointerventionalMRIisthereforestillrestricted

andfarlessopenthaninotherwesterncountries,although

thecountryisgraduallyequippingitselfthrough

technolog-icaladvances(coils,biopsy systemsetc.)andinvestments

fromthedifferentpartiesinvolved.Only43procedureswere

recordedin2006andofthe200Frenchsiteswherebreast

MRIwasbeingperformedin2009,36hadaninterventional

breast coil and 14 were using it (survey by the Société

franc¸aisederadiologie—Sociétéfranc¸aisedemastologieet

d’imageriedusein).Atleast20procedureswerecarriedout

per yearin fourcentersand amaximum ten in theother

centers.

The ﬁvemaincenterscurrentlycarryoutanaverageof

aroundﬁftyproceduresannually.

According tothe HAS, the target population is 100 to

700/year(thisnumberwasobtainedfromtheannualactivity

ofthe14referencecenters)[50].

SomerecommendthatallsiteswherebreastMRIis

per-formedalsoofferMRI-guidedvacuum-assistedbiopsies[47],

althoughcurrentlythisappearsunrealisticinFranceandthe

aimisratherthatthesesitescollaboratewitha

neighbor-ingcenter wherethe differentMRIguided proceduresare

performed[50].

Conclusion

MRI-guided, vacuum-assisted biopsy has remained a con-ﬁdential home-grown technique for years [7,89,92,140],

reservedfor some centers only asit is a time consuming

examination withvery limited indications and no speciﬁc

tariffinFrance.

Inaddition,thelack ofaradiological imagetoconﬁrm

that the samples were representative and the

radio-histologicalcorrelationclearlyraisetechnicaldifﬁculties.

Despitethesevariouslimitations,itisamajortechnique,

whichcanoptimizetheinformationprovidedbybreastMRI,

anessentialconditionforittodevelop[96].

Majortechnicaladvances(coilsandsoftware,etc.)have

increasedreproducibilityinrecentyears.Thisisnowa

vali-datedtechniqueofferinghighlevelsofconcordanceandlow

underestimationrates,whichisreservedmostlyfor

special-istcenters[50].

Tools such as spectroscopy and high ﬁelds may in the

futureincreasethespeciﬁcityofMRIallowingbetter

selec-tionsoflesionstobebiopsiedandthedetectionofpossible

post-biopsyresidualtumor.

Disclosure

of

interest

Theauthorsdeclarethattheyhavenoconﬂictsofinterest concerningthisarticle.

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