Which procedures use ultrasound-guidance for the treatment for breast cancer?

Updated: Feb 01, 2017
  • Author: Paul R Fisher, MD; Chief Editor: Eugene C Lin, MD  more...
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Answer

Ultrasonography is used to guide procedures such as cyst aspiration, percutaneous biopsy, needle localization of masses for surgical excision, abscess drainage in selected cases, and therapeutic radiofrequency or cryoablation.

Ultrasonography is highly accurate in diagnosing a simple cyst, and it is helpful in evaluating some complex cysts. Usually, a simple cyst is not aspirated unless they it is symptomatic or the patient has persistent psychological concerns about it. Complex cysts or suspected abscesses may be aspirated.

Berg et al reviewed their experience with the US-pathologic correlation of cystic lesions and found that all clustered microcysts were benign, but they cautioned that further study is required. [55] They recommended that biopsy be performed in cases involving (1) cystic lesions with thick, indistinct walls and/or thick septations (0.5 mm); (2) intracystic masses; and (3) predominantly solid masses with eccentric cystic foci. These recommendations were based on the fact that, in their series, 18 of 79 of such complex cystic lesions proved to be malignant.

If it is uncertain whether a nodule seen on US is a complex cyst or solid mass, US-guided aspiration of the cyst is often performed. This procedure is also performed if the appearance of a complex cyst on US is of concern. The aspirate may be sent for cytologic evaluation, though there is no general consensus about the indications for cytology. Some clinicians send only the fluid for analysis if it is bloody.

Parker et al reported excellent concordance between the results of US-guided automated core biopsy with a 14-gauge needle and surgical resection in 49 lesions. [56] US provides effective guidance for percutaneous breast biopsy without ionizing radiation. It also offers the advantages of real-time visualization of the needle and target lesion, multidirectional imaging, and low cost. With US, the patient does not need to undergo mammographic compression; in addition, with US, the examination may usually be performed with the patient recumbent rather than sitting, as is often the case with procedures involving mammographic guidance. However, US is not appropriate for guidance in all situations. For instance, microcalcifications often cannot be localized with US; in addition, not all masses seen on mammography can be seen with US.

Other biopsy devices, such as vacuum-assisted devices, have been developed for use with US guidance. Occasionally, it may be difficult to find the area in the breast where core biopsy was previously performed. This may be a problem if the pathologic results from the biopsy sample and other factors indicate that excisional biopsy or lumpectomy is needed. After a patient receives preoperative neoadjuvant chemotherapy, the tumor may become occult, making it difficult to localize for lumpectomy. For these reasons, various US techniques to mark the biopsy or tumor site have been developed. These include the deployment of coils, clips, or wires.

US-guided fine-needle aspiration biopsy (FNAB) of solid nodules has been used at many centers. Some advantages are that it is relatively easy for a skilled practitioner to perform and that the results are quickly obtained if a cytopathologist is available. For good results, the person performing the FNAB and the cytopathologist must be skilled. Some groups have achieved excellent results. However, in a study by Pisano et al involving 18 institutions, US-guided or stereotactically guided FNAB yielded a 10% insufficient-sample rate for US-guided FNAB of masses. [57] This finding does not compare favorably with results of US-guided core biopsy or US-guided needle localization. [58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71]

Several investigators have presented preliminary reports on the use of US-guided therapeutic radiofrequency ablation or cryoablation of invasive breast carcinoma. [72, 73, 74]


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