Vacuum-Assisted Breast 2
Biopsy and Excision Systems
Renzo Brun del Re (Ed.), Minimally Invasive Breast Biopsies, Recent Results in Cancer Research 173, 23
Doi: 10.1007/978-3-540-31611-4_2, © Springer-Verlag Berlin Heidelberg 2009
24 R. Wilson and S. Kavia
necessary to achieve the tissue needed for reli- stereotactic (upright and prone table), and MR
able histopathological assessment (Kettritz et imaging guidance; the single intact biopsy sys-
2 al. 2003). With these two factors in mind, in the tem is described as being suitable for ultrasound
early 1990s techniques were developed to pro- and X-ray stereotactic-guided biopsy. All the
vide both directional sampling capability and systems are suitable for use in the out-patient
retrieval of larger volumes of tissue (Parker setting with local anesthesia.
et al. 1994; Burbank 1993). These have been
further developed and refined over the past 15
years and are now in routine use for both diag- 2.2.1
nosis and therapeutic excision. Single Large-Core Biopsy System
Two different approaches for large-core
biopsy have been developed: multiple contigu- The Intact Breast Lesion Excision System
ous large-bore cores retrieved with the assistance (BLES; Intact Medical Corporation Inc.) is a
of suction (vacuum-assisted mammotomy; VAM) breast excision system that combines the use of
and single very-large-bore core (SLCB). Both vacuum and radiofrequency (RF) cutting to
methods can be used under X-ray (stereotactic remove the targeted lesion as a single specimen
guidance) and ultrasound, but currently only (Intact Medical Corporation 2008). The probe
VAM is recommended for magnetic resonance (or wand) (Fig. 2.1) is available in four sizes,
(MR)-guided biopsy. With these techniques, it is designed to retrieve specimens that are 10, 12,
now possible to retrieve sufficient tissue using 15, and 20 mm in diameter (Fig. 2.2). The
image-guided biopsy such that 98–99% accuracy Intact BLES probe is positioned under imaging
of nonsurgical diagnosis can be achieved. In fact, guidance (ultrasound or X-ray stereotaxis)
so much tissue can be removed that these tech- through a 6- to 8-mm skin incision and
niques are now being used for total excision of advanced to the periphery of the area to be
certain breast abnormalities. Compared to core excised. A cutting RF wire is activated and
biopsy, VAM and very-large-core biopsy reduce advanced to cut and ensnare the target lesion
by half understaging of pathology (atypical by means of four insulated struts that first
hyperplasia and DCIS), on average from 20 to expand and then contract to surround the lesion
10%. This means that repeat biopsy and further (Fig. 2.3). The single large sample is then
surgery for diagnosis and treatment are required withdrawn intact through the same tract.
half as often (Liberman et al. 2000). Vacuum- Vacuum is used to minimize the extent of the
assisted biopsy is the technique of first choice RF effect on the sample excised and into the
for MR-guided breast biopsy (Liberman et al. surrounding breast tissue and to extract any
2005; Kuhl 2007). bleeding that may occur during the procedure.
The Intact BLES system is said to have the
advantage over VAM of retaining the full
histological architecture and potentially clear
2.2 margins around the area of interest and with
Large-Core Biopsy Systems: Overview little RF artifact on histology (Sie et al. 2006).
It has also been reported to be associated with
Currently one single large-core radiofrequency reduced understaging compared to VAM (Sie
biopsy system and four vacuum-assisted multi- et al. 2006; Killebrew and Oneson 2006).
ple-core biopsy systems are in routine use for However, the RF function does limit its use for
breast diagnosis and excision. All of the VAM lesions close to the skin or the chest wall and
systems are suitable for use under ultrasound, for lesions in small breasts.
2 Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 25
Fig. 2.2 Intact whole-tissue samples showing the size of samples achieved with the 10-, 12-, 15-, and
20-mm wands
a b
Fig. 2.4 Mammotome biopsy probes (a) ultrasound EX system and (b) stereotactic ST system
Fig. 2.6 The Encor (left), Atec (middle), and Mammotome (right) control modules
Fig. 2.7 The Mammotome control module monitor showing the operating functions
from the sample collection chamber after scalpel embedded into the probe tip (Fig.
each biopsy (Fig. 2.9). The probes are dispos- 2.5). The 11-G probe provides approximately
able and are available in two sizes (11 and 8 100 mg and the 7-G probe approximately 175
G) for ultrasound, stereotactic, and MR use mg of tissue per core sample. Special part-
and are available with or without a cutting ceramic probes, guides, and introducers are
2 Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 29
a b
Fig. 2.8 The Mammotome ST system a showing the ital stereotactic system (GE Medical Systems) with
set-up for use with a lateral arm and b for biopsy of the patient in the lateral decubitus position
the inferior part of the breast using an upright dig-
Fig. 2.9 The Mammotome ST system in use for biopsy of the upper breast in the craniocaudal position
using an upright stereotactic system (GE Medical Systems) showing manual retrieval of a core sample
a b
2
Fig. 2.10 The Bard Vacora vacuum biopsy system: a driver, b the system ready for use, and c a close-up
the handheld device showing insertion of the nee- view of the operating panel
dle and the self-contained vacuum system into the
Fig. 2.12 The Bard Vacora system in use for MRI-guided breast biopsy. The black line on the back of the
device indicates the direction of sampling
canula. The system incorporates a spring-loaded able in 9- and 12-cm lengths, both with 20-mm
firing mechanism that allows the needle to be sampling chambers. The larger 9-G needles are
fired forward into the breast. The system is available in 9-, 12-, and 14-cm lengths with
simple to use because its functions are all preset the two shorter lengths available with either
and are activated using the control panel on the 20- or 12-mm sampling chambers (Fig. 2.14).
side of the device; changes to its operation The sampling processes are preset and not
cannot be programmed by the user. programmable by the user. All handpieces include
a closed sample collection system (Fig. 2.14).
There are two operation modes that are used
2.2.2.3 for all methods of image guidance (Fig. 2.15). In
ATEC (Automatic Tissue Extraction and Collection) the lavage mode the sample chamber is open
and saline is continuously instilled through the
The Automatic Tissue Extraction and Collection system into the biopsy area and through the
(ATEC) system (Suros Inc.) is similar in its sampling filter (Fig. 2.15). The ATEC is the only
function to the Mammotome ST system in that it system that uses lavage of the biopsy area.
is driven by cables from the command unit and Manual suction can also be applied (Fig. 2.15).
uses an internal rotating cutter. However, it is a In the biopsy mode, the sample chamber is
single-bore system and the whole driver unit is closed in the resting position until the foot pedal
disposable (Fig. 2.13). There are three different is used to trigger multiple rapid retrievals of
command modules available that deliver differing samples (averaging 150–175 mg per core). The
suction levels depending or required usage (MR ATEC is the fastest-acting VAM system,
only, ultrasound and stereotactic only, and all although it does not deliver more tissue per time
three). The disposable handpieces are available unit than the EnCor system (see below).
in two needle sizes in several lengths and sampling Directional sampling is achieved by rotating the
chamber sizes. Twelve-gauge needles are avail- handpiece manually (Fig. 2.16). The needle of
32 R. Wilson and S. Kavia
a b
2
Fig. 2.13 The Suros ATEC biopsy device a showing the component parts with the disposable driver and
detached closed sampling chamber and b close-up of the closed sampling chamber in place
Fig. 2.16 The Suros ATEC system in use for ultrasound-guided biopsy
chamber length (10 or 20 mm) for the two needle larly dense tissue is encountered. The module
sizes can be set at the control module and avoids also has a preset anesthetic function that allows
the need to select a different needle if a short for delivery of local anesthetic 360° around the
core length is required. The strength of the vac- biopsy site either before or during the biopsy
uum applied can also be doubled when particu- procedure. The same system is used to deploy
34 R. Wilson and S. Kavia
a b
2
Fig. 2.19 The Suros EnCor system set up and ready for handheld use
2.3
Fig. 2.20 The Suros EnCor system in place for ster- Indications and Limitations
eotactic-guided biopsy using a prone table
There are a number of diagnostic and therapeu-
gel and clip markers at the biopsy site (Fig. 2.22). tic situations where VAM or SLCB should be
The closed sample collection system retrieves considered as the primary technique. These
the samples in an easily removable basket that include:
36 R. Wilson and S. Kavia
a a
2
a b
Fig. 2.24 Stereotactic procedure radiograph showing a an EnCor probe in place for biopsy of calcifica-
tions, b core specimens in the sample retrieval tray, and c radiography showing calcifications success-
fully sampled
38 R. Wilson and S. Kavia
mum diameter of 20 mm. The Mammotome (7 breast throughout the biopsy procedure and are
G), ATEC (9 G), and EnCor (7 G) are all ideal for therefore easier to use in this situation. All of the
excision of large lesions. The Mammotome sys- systems are light enough to be easily handheld
tem takes longer to complete the task simply for ultrasound-guided use. The sharpness of the
because each sample has to be retrieved from the tri-concave tip of the Encor system means that it
sample chamber while with the other two the is more easily advanced through the breast to the
samples are automatically collected by their target than the other systems and is more easily
closed sampling systems. Many clinicians restrict sited in the ideal position for ultrasound-guided
the size of lesion they are willing to attempt to VAM immediately behind the lesion (Fig. 2.21).
remove with VAM to around 20–30 mm. Both the This is particularly apparent in the dense and
EnCor and ATEC systems will retrieve more than fibrous breast.
1 g of tissue per minute and can be readily used to
excise lesions up to 50–60 mm in diameter.
There are also some reports of these tech- 2.3.4
niques being used to sample sentinel nodes prior Image-Guided Biopsy Technique
to surgery or primary chemotherapy treatment.
However, this indication must be considered Anyone familiar with the technique for image-
experimental at present. Similarly, SLCB and guided fine-needle aspiration and conventional
VAM should not be used for excision of known core biopsy will be able to adapt easily to the
malignant lesions or borderline lesions associ- technique required for large-core biopsy because
ated with a significant risk of breast cancer the basic principles are the same.
except in exceptional circumstances (Eby et al. Particular attention must be paid to adminis-
2008; Lee et al. 2008). In some patients who are tration of sufficient local anesthetic for these
not medically fit for conventional treatment large-bore procedures. Significantly larger
(surgery and chemotherapy), SLCB and VAM doses are usually required than for conventional
can be considered. To ensure a reasonable exci- core biopsy, particularly for excision proce-
sion margin, the Intact system should be con- dures and procedures done under ultrasound
fined to lesions no more than 10–25 mm in guidance. The larger size and vacuum assist-
diameter if a clear excision margin is to be ance both mean that vessel damage is more
achieved. The VAM system can be used for likely with these techniques. The use of local
larger lesions but it must be recognized that the aesthetic combined with adrenaline is preferred
excision margins will be suspect, even if sample because this reduces the chances of hematoma
mapping is used. and increases the time that the anesthesia is
As with all breast biopsies, ultrasound guid- effective. Plain local anesthetic may be pre-
ance is the preferred guidance method whenever ferred for the skin and subcutaneous tissues in
possible. All of the systems described here can older patients and those with compromised
be used for ultrasound-guided biopsy. The skin. For stereotactic X-ray-guided procedures,
Vacora system is usually used with a trocar. For care should be taken not to inject large volumes
stereotactic biopsy, this is satisfactory because of anesthetic since this can significantly displace
the breast is fixed by compression. For ultra- the target area. The biopsy-targeting process is
sound, the trocar guide system can be less effec- the same as for core biopsy with the aim of
tive, particularly in the large breast; since the passing the probe directly through the area to
breast is not fixed, it can be difficult to reintro- be sampled and then biopsy around 360°.
duce the needle to the same site for successive However, unlike core biopsy, successful sampling
biopsies. The other VAM systems remain in the can be achieved if the lesion is not transfixed
40 R. Wilson and S. Kavia
using the vacuum and directional capabilities of provide the means for minimally invasive ther-
the VAM systems. apeutic lesion excision of benign and border-
2 For ultrasound-guided sampling, the anes- line lesions. Accuracy approaching 99% can be
thetic must be infiltrated to surround the lesion achieved, thus avoiding the need for diagnostic
being targeted and can be used to dissect the tis- surgical open biopsy in the vast majority of
sue down to the lesion and to assist in separating cases and providing tissue samples in quanti-
the target from the deep and superficial tissues. ties sufficient to allow for detailed treatment
Deep tissue anesthesia is particularly important, planning. The choice of vacuum biopsy system
as for ultrasound-guided sampling the VAM will depend on workload, the image guidance
probe is best positioned behind the lesion. Some methods that are used, and whether lesion exci-
also advocate the use of longer-acting local sion is required.
anesthetic in the deeper tissues around the target
lesion to reduce postprocedure anesthesia.
All but the Vacora system allow for further
References
injection of local anesthetic through the biopsy
probe into the target area (Fig. 2.22b). This can Bassett L, Winchester DP, Caplan RB et al (1997)
be done as a matter of routine before the biopsy Stereotactic core needle biopsy of the breast: a
is commenced, particularly for stereotactic pro- report of the joint task force of the American
cedures when the probe has been placed and dis- College of Surgeons and College of American
placement of the lesion is then less likely to Pathologists. CA Cancer J Clin 47:171
Burbank F (1993) Stereotactic breast biopsy: com-
occur. The EnCor device has a specific program parison of 14- and 11-guage mammotome probe.
for delivering local anesthetic around the area to Acta Cytol 37:461–471
be biopsied. Carder PJ, Khan T, Burrows P, Sharma N (2008)
MR-guided biopsy can be achieved with all Large volume mammotome biopsy may reduce
of the VAM systems described (Figs. 2.12 and the need for diagnostic surgery in papillary
lesions of the breast. J Clin Pathol 61:928–933
2.23b). All of the manufacturers provide MR Eby PR, Ochsner JE, DeMartini WB, Allison KH,
biopsy packs that contain the necessary materi- Peacock S, Lehman CD (2008) Is surgical exci-
als to carry out the procedure using most of the sion necessary for focal atypical ductal hyperpla-
currently available MR biopsy coil systems sia found at stereotactic vacuum-assisted biopsy.
(Fig. 2.23a). VAM is recommended for all Annu Surg Oncol 15;3232–3238
Georgian-Smith D, D’Orsi C, Morris E, Clark CF,
MR-guided biopsies; these lesions are only vis- Liberty E, Lehman CD (2002) Stereotactic
ible on MR and therefore the method most biopsy of the breast using an upright unit, a
likely to successfully retrieve tissue from the vacuum suction needle, and a lateral arm sup-
targeted area should be used (Lee et al. 2008). port. AJR 178:1017–1024
Intact Medical Corporation (2008) Percutaneous
contiguous electrosurgical breast biopsy devices.
http://www.intactmedical.com/pdf/ML087_
Rev00.pdf
Kellebrew LK, Oneson RH (2006) Comparison of
2.4 the diagnostic accuracy of a vacuum-assisted
Conclusions percutaneous intact specimen sampling device to
a vacuum-assisted core needle sampling device
There are a number of well-designed devices for breast biopsy: initial experience. Breast
12:302–308
available for vacuum biopsy and excision Kettritz U et al (2003) Stereotactic vacuum-assisted
biopsy. These devices enable the radiologist to breast biopsy in 2874 patients: a multicentre
deliver a high level of diagnostic accuracy and study. Cancer 100:245–251
2 Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 41
Kuhl C (2007) The current status of breast MR imag- Parker SH, Dennis MA, Stavros AT, Johnson KK
ing. Part 1. Choice of technique, image interpre- (2006) A new breast biopsy technique. J Diagn
tation, diagnostic accuracy, and transfer of Med Sonogr 12:113–118
clinical practice. Radiology 244:356–378 Philpotts LE, Hooley RJ, Lee CH (2003) Comparison
Lee K-M, Kaplan JB, Murray MP, Liberman L of automated versus vacuum-assisted methods
(2008) Complete excision of the MRI target for sonographically guided core biopsy of the
lesion at MRI-guided vacuum-assisted biopsy of breast. AJR 180:347–351
breast cancer. AJR 191:1198–1202 Rosen EL, Bentley RC, Baker JA, Soo MS (2002)
Liberman L (2000) Percutaneous image-guided core Imaging-guided core needle biopsy of papillary
biopsy: state of the art at the millennium. AJR lesions of the breast. AJR 179:1185–1192
174:1191–1199 Schueller G et al (2008) US-guided 14 gauge core
Liberman L, Bracero N, Morris E, Thornton C, needle breast biopsy: results of a validation study
Dershaw DD (2005) MRI-guided 9-guage vac- in 1352 cases. Radiology 248:406–413
uum assisted breast biopsy: initial clinical expe- Sie A et al (2006) Multi-center evaluation of the
rience. AJR 185:183–193 breast lesion excision system, a percutaneous,
Litherland J (2001) The role of needle biopsy in vacuum-assisted intact-specimen breast biopsy
the diagnosis of breast lesions. Breast 10: device. Cancer 107:945–949
383–387 Teh W, Evans AJ, Wilson ARM (1998) Editorial.
Parker SH, Burbank F (1996) A practical approach Definitive non-surgical breast diagnosis: the role
to minimally invasive breast biopsy. Radiology of the radiologist. Clin Radiol 53:81–84
200:11–20 Tennant SL, Evans AJ, Hamilton LJ, James J, Lee AH,
Parker SH, Burbank F, Jackman J, Aucreman CJ, Hodi Z, Ellis IO, Rakha EA, Wilson AR (2008)
Cardenosa G, Clink TM et al (1994) Percutaneous Vacuum-assisted excision of breast lesions of
large-core breast biopsy: a multi-institutional uncertain malignant potential (B3) - an alternative
study. Radiology 3:359–363 to surgery in selected cases. Breast 17(6):546–549
http://www.springer.com/978-3-540-31403-5