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Stereotactic Biopsy, Upright
Ethan O. Cohen, MD; Lumarie Santiago, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Definitions

              • Mammographically guided biopsy using 2 stereotactic images (taken at +15° and -15° angles) or 1 tomosynthesis series for targeting; patient seated or lateral decubitus position
              • Standard mammography tower + biopsy attachment
                • Pros: Existing equipment, ↑ access to posterior lesions, ↑ patient comfort, faster than prone
                  • Mean 12 min vs. 27 min for prone (1 series)
                  • Sensitivity (96%), specificity (100%), and accuracy (98%) = prone biopsy (1 series)
                • Cons: Vasovagal reactions, ↑ potential for patient motion
                  • Vasovagal reaction rate: 7% for upright vs. 2% for prone (1 series)
                  • Inferior approach not feasible directly: Requires lateral decubitus positioning, which is not always possible
              • Biopsy devices
                • 14-g automated core needle biopsy (CNB)
                  • ↓ bleeding but ↑ false negatives
                • Vacuum-assisted needle biopsy (VAB)
                  • 7-g to 12-g; most often 9- or 11-g
                  • Variable aperture and clip deployment methods
                  • Pros: ↑ accuracy/calcification retrieval, ↓ underestimation of pathology
                  • Cons: ↑ risk of bleeding

            PREPROCEDURE

            • Indications

              • Contraindications

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Equipment Preparation

                      • Procedure Steps

                        • Findings and Reporting

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Expected Outcome

                              • Things to Do

                                • Things to Avoid

                                  OUTCOMES

                                  • Problems

                                    • Complications

                                      Selected References

                                      1. Bahl M et al: Comparison of upright digital breast tomosynthesis-guided versus prone stereotactic vacuum-assisted breast biopsy. Radiology. 181788, 2018
                                      2. Jain A et al: Stereotactic core needle breast biopsy marker migration: an analysis of factors contributing to immediate marker migration. Eur Radiol. 27(11):4797-803, 2017
                                      3. Omofoye TS et al: Implementation of upright digital breast tomosynthesis-guided stereotactic biopsy. Acad Radiol. 24(11):1451-5, 2017
                                      4. Ruggirello I et al: Stereotactic vacuum-assisted breast biopsy: comparison between 11- and 8-gauge needles. Eur J Surg Oncol. 43(12):2257-60, 2017
                                      5. monticciolo DL et al: Six-month short-interval imaging follow-up for benign concordant core needle biopsy of the breast: outcomes in 1444 cases with long-term follow-up. AJR Am J Roentgenol. 1-6, 2016
                                      6. Mooney KL et al: Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review. Mod Pathol. 29(12):1471-1484, 2016
                                      7. Johnson JM et al: Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results. Radiology. 275(1):54-60, 2015
                                      8. Schrading S et al: Digital breast tomosynthesis-guided vacuum-assisted breast biopsy: initial experiences and comparison with prone stereotactic vacuum-assisted biopsy. Radiology. 274(3):654-62, 2015
                                      9. Ohsumi S et al: Breast biopsy for mammographically detected nonpalpable lesions using a vacuum-assisted biopsy device (Mammotome) and upright-type stereotactic mammography unit without a digital imaging system: experience of 500 biopsies. Breast Cancer. 21(2):123-7, 2014
                                      10. Mahoney MC et al: Breast intervention: how I do it. Radiology. 268(1):12-24, 2013
                                      11. Viala J et al: Stereotactic vacuum-assisted biopsies on a digital breast 3D-tomosynthesis system. Breast J. 19(1):4-9, 2013
                                      12. Becker DE et al: Local anesthetics: review of pharmacological considerations. Anesth Prog. 59(2):90-101; quiz 102-3, 2012
                                      13. Gümüş H et al: Causes of failure in removing calcium in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy. Diagn Interv Radiol. 18(4):354-9, 2012
                                      14. Schaefer FK et al: Interventional bleeding, hematoma and scar-formation after vacuum-biopsy under stereotactic guidance: Mammotome(®)-system 11 g/8 g vs. ATEC(®)-system 12 g/9 g. Eur J Radiol. 81(5):e739-45, 2012
                                      15. Ames V et al: Stereotactically guided breast biopsy: a review. Insights Imaging. 2(2):171-176, 2011
                                      16. Cummings DR et al: Complications of local anesthesia used in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am. 23(3):369-77, 2011
                                      17. Jung YJ et al: Lateral decubitus positioning stereotactic vacuum-assisted breast biopsy with true lateral mammography. J Breast Cancer. 14(1):64-8, 2011
                                      18. Baldwin P: Breast biopsy targeting techniques. Radiol Technol. 82(1):59M-79M, 2010
                                      19. Bruening W et al: Systematic review: comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med. 152(4):238-46, 2010
                                      20. Neal JM et al: ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 35(2):152-61, 2010
                                      21. Ma K et al: A new lateral guidance device for stereotactic breast biopsy using an add-on unit to an upright mammography system. Conf Proc IEEE Eng Med Biol Soc. 2008:3653-6, 2008
                                      22. Sim LS et al: Upright stereotactic vacuum-assisted needle biopsy of suspicious breast microcalcifications. J Med Imaging Radiat Oncol. 52(4):358-64, 2008
                                      23. Somerville P et al: Anticoagulation and bleeding risk after core needle biopsy. AJR Am J Roentgenol. 191:1194-7, 2008
                                      24. Fahrbach K et al: A comparison of the accuracy of two minimally invasive breast biopsy methods: a systematic literature review and meta-analysis. Arch Gynecol Obstet. 274(2):63-73, 2006
                                      25. Uriburu JL et al: Local recurrence of breast cancer after skin-sparing mastectomy following core needle biopsy: case reports and review of the literature. Breast J. 12(3):194-8, 2006
                                      26. Yazici B et al: Scar formation after stereotactic vacuum-assisted core biopsy of benign breast lesions. Clin Radiol. 61(7):619-24, 2006
                                      27. James JJ et al: The use of a short-acting benzodiazepine to reduce the risk of syncopal episodes during upright stereotactic breast biopsy. Clin Radiol. 60(3):394-6, 2005
                                      28. Koskela AK et al: Add-on device for stereotactic core-needle breast biopsy: how many biopsy specimens are needed for a reliable diagnosis? Radiology. 236(3):801-9, 2005
                                      29. McLure HA et al: Review of local anaesthetic agents. Minerva Anestesiol. 71(3):59-74, 2005
                                      30. Della Sala SW et al: Advantages and limits of percutaneous breast core biopsy with Mammotome and stereotactic equipment in upright seated patient. Radiol Med. 108(4):335-44, 2004
                                      31. Esserman LE et al: Recognizing pitfalls in early and late migration of clip markers after imaging-guided directional vacuum-assisted biopsy. Radiographics. 24(1):147-56, 2004
                                      32. Lomoschitz FM et al: Stereotactic 11-gauge vacuum-assisted breast biopsy: influence of number of specimens on diagnostic accuracy. Radiology. 232(3):897-903, 2004
                                      33. Margolin FR et al: Metallic marker placement after stereotactic core biopsy of breast calcifications: comparison of two clips and deployment techniques. AJR Am J Roentgenol. 181(6):1685-90, 2003
                                      34. Achar S et al: Principles of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician. 66(1):91-4, 2002
                                      35. Kass R et al: Clip migration in stereotactic biopsy. Am J Surg. 184(4):325-31, 2002
                                      36. Meloni GB et al: Percutaneous vacuum-assisted core breast biopsy with upright stereotactic equipment. Indications, limitations and results. Acta Radiol. 43(6):575-8, 2002
                                      37. Sittek H et al: [Stereotactic vacuum biopsy in prone and sitting position.] Radiologe. 42(1):19-24, 2002
                                      38. Wunderbaldinger P et al: Comparison of sitting versus prone position for stereotactic large-core breast biopsy in surgically proven lesions. AJR Am J Roentgenol. 178(5):1221-5, 2002
                                      39. Becker L et al: Stereotactic core biopsy of breast microcalcifications: comparison of film versus digital mammography, both using an add-on unit. AJR Am J Roentgenol. 177(6):1451-7, 2001
                                      40. Norris TG: Stereotactic breast biopsy. Radiol Technol. 72(5):431-50; quiz 451-4, 2001
                                      41. Pisano ED et al: Fine-needle aspiration biopsy of nonpalpable breast lesions in a multicenter clinical trial: results from the radiologic diagnostic oncology group V. Radiology. 219(3):785-92, 2001
                                      42. Sneige N et al: Accuracy of cytologic diagnoses made from touch imprints of image-guided needle biopsy specimens of nonpalpable breast abnormalities. Diagn Cytopathol. 23(1):29-34, 2000
                                      43. Keyes PD et al: Topical anesthesia. Can Fam Physician. 44:2152-6, 1998
                                      44. Lankford KV et al: Utilization of core wash material in the diagnosis of breast lesions by stereotactic needle biopsy. Cancer. 84(2):98-100, 1998
                                      45. Meechan J: How to avoid local anaesthetic toxicity. Br Dent J. 184(7):334-5, 1998
                                      46. Burbank F et al: Tissue marking clip for stereotactic breast biopsy: initial placement accuracy, long-term stability, and usefulness as a guide for wire localization. Radiology. 205(2):407-15, 1997
                                      47. Burbank F: Mammographic findings after 14-gauge automated needle and 14-gauge directional, vacuum-assisted stereotactic breast biopsies. Radiology. 204(1):153-6, 1997
                                      48. Fuhrman G et al: Stereotactic core needle breast biopsy is an accurate diagnostic technique to assess nonpalpable mammographic abnormalities. J La State Med Soc. 148(4):167-70, 1996
                                      49. Parker SH et al: Nonpalpable breast lesions: stereotactic automated large-core biopsies. Radiology. 180(2):403-7, 1991
                                      50. Lofgren M et al: Stereotactic fine-needle aspiration for cytologic diagnosis of nonpalpable breast lesions. AJR Am J Roentgenol. 154(6):1191-5, 1990
                                      51. Parker SH et al: Stereotactic breast biopsy with a biopsy gun. Radiology. 176(3):741-7, 1990
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Preprocedure

                                          • Procedure

                                            • Post Procedure

                                              • Outcomes

                                                TERMINOLOGY

                                                • Definitions

                                                  • Mammographically guided biopsy using 2 stereotactic images (taken at +15° and -15° angles) or 1 tomosynthesis series for targeting; patient seated or lateral decubitus position
                                                  • Standard mammography tower + biopsy attachment
                                                    • Pros: Existing equipment, ↑ access to posterior lesions, ↑ patient comfort, faster than prone
                                                      • Mean 12 min vs. 27 min for prone (1 series)
                                                      • Sensitivity (96%), specificity (100%), and accuracy (98%) = prone biopsy (1 series)
                                                    • Cons: Vasovagal reactions, ↑ potential for patient motion
                                                      • Vasovagal reaction rate: 7% for upright vs. 2% for prone (1 series)
                                                      • Inferior approach not feasible directly: Requires lateral decubitus positioning, which is not always possible
                                                  • Biopsy devices
                                                    • 14-g automated core needle biopsy (CNB)
                                                      • ↓ bleeding but ↑ false negatives
                                                    • Vacuum-assisted needle biopsy (VAB)
                                                      • 7-g to 12-g; most often 9- or 11-g
                                                      • Variable aperture and clip deployment methods
                                                      • Pros: ↑ accuracy/calcification retrieval, ↓ underestimation of pathology
                                                      • Cons: ↑ risk of bleeding

                                                PREPROCEDURE

                                                • Indications

                                                  • Contraindications

                                                    • Getting Started

                                                      PROCEDURE

                                                      • Patient Position/Location

                                                        • Equipment Preparation

                                                          • Procedure Steps

                                                            • Findings and Reporting

                                                              • Alternative Procedures/Therapies

                                                                POST PROCEDURE

                                                                • Expected Outcome

                                                                  • Things to Do

                                                                    • Things to Avoid

                                                                      OUTCOMES

                                                                      • Problems

                                                                        • Complications

                                                                          Selected References

                                                                          1. Bahl M et al: Comparison of upright digital breast tomosynthesis-guided versus prone stereotactic vacuum-assisted breast biopsy. Radiology. 181788, 2018
                                                                          2. Jain A et al: Stereotactic core needle breast biopsy marker migration: an analysis of factors contributing to immediate marker migration. Eur Radiol. 27(11):4797-803, 2017
                                                                          3. Omofoye TS et al: Implementation of upright digital breast tomosynthesis-guided stereotactic biopsy. Acad Radiol. 24(11):1451-5, 2017
                                                                          4. Ruggirello I et al: Stereotactic vacuum-assisted breast biopsy: comparison between 11- and 8-gauge needles. Eur J Surg Oncol. 43(12):2257-60, 2017
                                                                          5. monticciolo DL et al: Six-month short-interval imaging follow-up for benign concordant core needle biopsy of the breast: outcomes in 1444 cases with long-term follow-up. AJR Am J Roentgenol. 1-6, 2016
                                                                          6. Mooney KL et al: Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review. Mod Pathol. 29(12):1471-1484, 2016
                                                                          7. Johnson JM et al: Breast cancer detection with short-interval follow-up compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy results. Radiology. 275(1):54-60, 2015
                                                                          8. Schrading S et al: Digital breast tomosynthesis-guided vacuum-assisted breast biopsy: initial experiences and comparison with prone stereotactic vacuum-assisted biopsy. Radiology. 274(3):654-62, 2015
                                                                          9. Ohsumi S et al: Breast biopsy for mammographically detected nonpalpable lesions using a vacuum-assisted biopsy device (Mammotome) and upright-type stereotactic mammography unit without a digital imaging system: experience of 500 biopsies. Breast Cancer. 21(2):123-7, 2014
                                                                          10. Mahoney MC et al: Breast intervention: how I do it. Radiology. 268(1):12-24, 2013
                                                                          11. Viala J et al: Stereotactic vacuum-assisted biopsies on a digital breast 3D-tomosynthesis system. Breast J. 19(1):4-9, 2013
                                                                          12. Becker DE et al: Local anesthetics: review of pharmacological considerations. Anesth Prog. 59(2):90-101; quiz 102-3, 2012
                                                                          13. Gümüş H et al: Causes of failure in removing calcium in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy. Diagn Interv Radiol. 18(4):354-9, 2012
                                                                          14. Schaefer FK et al: Interventional bleeding, hematoma and scar-formation after vacuum-biopsy under stereotactic guidance: Mammotome(®)-system 11 g/8 g vs. ATEC(®)-system 12 g/9 g. Eur J Radiol. 81(5):e739-45, 2012
                                                                          15. Ames V et al: Stereotactically guided breast biopsy: a review. Insights Imaging. 2(2):171-176, 2011
                                                                          16. Cummings DR et al: Complications of local anesthesia used in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am. 23(3):369-77, 2011
                                                                          17. Jung YJ et al: Lateral decubitus positioning stereotactic vacuum-assisted breast biopsy with true lateral mammography. J Breast Cancer. 14(1):64-8, 2011
                                                                          18. Baldwin P: Breast biopsy targeting techniques. Radiol Technol. 82(1):59M-79M, 2010
                                                                          19. Bruening W et al: Systematic review: comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med. 152(4):238-46, 2010
                                                                          20. Neal JM et al: ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 35(2):152-61, 2010
                                                                          21. Ma K et al: A new lateral guidance device for stereotactic breast biopsy using an add-on unit to an upright mammography system. Conf Proc IEEE Eng Med Biol Soc. 2008:3653-6, 2008
                                                                          22. Sim LS et al: Upright stereotactic vacuum-assisted needle biopsy of suspicious breast microcalcifications. J Med Imaging Radiat Oncol. 52(4):358-64, 2008
                                                                          23. Somerville P et al: Anticoagulation and bleeding risk after core needle biopsy. AJR Am J Roentgenol. 191:1194-7, 2008
                                                                          24. Fahrbach K et al: A comparison of the accuracy of two minimally invasive breast biopsy methods: a systematic literature review and meta-analysis. Arch Gynecol Obstet. 274(2):63-73, 2006
                                                                          25. Uriburu JL et al: Local recurrence of breast cancer after skin-sparing mastectomy following core needle biopsy: case reports and review of the literature. Breast J. 12(3):194-8, 2006
                                                                          26. Yazici B et al: Scar formation after stereotactic vacuum-assisted core biopsy of benign breast lesions. Clin Radiol. 61(7):619-24, 2006
                                                                          27. James JJ et al: The use of a short-acting benzodiazepine to reduce the risk of syncopal episodes during upright stereotactic breast biopsy. Clin Radiol. 60(3):394-6, 2005
                                                                          28. Koskela AK et al: Add-on device for stereotactic core-needle breast biopsy: how many biopsy specimens are needed for a reliable diagnosis? Radiology. 236(3):801-9, 2005
                                                                          29. McLure HA et al: Review of local anaesthetic agents. Minerva Anestesiol. 71(3):59-74, 2005
                                                                          30. Della Sala SW et al: Advantages and limits of percutaneous breast core biopsy with Mammotome and stereotactic equipment in upright seated patient. Radiol Med. 108(4):335-44, 2004
                                                                          31. Esserman LE et al: Recognizing pitfalls in early and late migration of clip markers after imaging-guided directional vacuum-assisted biopsy. Radiographics. 24(1):147-56, 2004
                                                                          32. Lomoschitz FM et al: Stereotactic 11-gauge vacuum-assisted breast biopsy: influence of number of specimens on diagnostic accuracy. Radiology. 232(3):897-903, 2004
                                                                          33. Margolin FR et al: Metallic marker placement after stereotactic core biopsy of breast calcifications: comparison of two clips and deployment techniques. AJR Am J Roentgenol. 181(6):1685-90, 2003
                                                                          34. Achar S et al: Principles of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician. 66(1):91-4, 2002
                                                                          35. Kass R et al: Clip migration in stereotactic biopsy. Am J Surg. 184(4):325-31, 2002
                                                                          36. Meloni GB et al: Percutaneous vacuum-assisted core breast biopsy with upright stereotactic equipment. Indications, limitations and results. Acta Radiol. 43(6):575-8, 2002
                                                                          37. Sittek H et al: [Stereotactic vacuum biopsy in prone and sitting position.] Radiologe. 42(1):19-24, 2002
                                                                          38. Wunderbaldinger P et al: Comparison of sitting versus prone position for stereotactic large-core breast biopsy in surgically proven lesions. AJR Am J Roentgenol. 178(5):1221-5, 2002
                                                                          39. Becker L et al: Stereotactic core biopsy of breast microcalcifications: comparison of film versus digital mammography, both using an add-on unit. AJR Am J Roentgenol. 177(6):1451-7, 2001
                                                                          40. Norris TG: Stereotactic breast biopsy. Radiol Technol. 72(5):431-50; quiz 451-4, 2001
                                                                          41. Pisano ED et al: Fine-needle aspiration biopsy of nonpalpable breast lesions in a multicenter clinical trial: results from the radiologic diagnostic oncology group V. Radiology. 219(3):785-92, 2001
                                                                          42. Sneige N et al: Accuracy of cytologic diagnoses made from touch imprints of image-guided needle biopsy specimens of nonpalpable breast abnormalities. Diagn Cytopathol. 23(1):29-34, 2000
                                                                          43. Keyes PD et al: Topical anesthesia. Can Fam Physician. 44:2152-6, 1998
                                                                          44. Lankford KV et al: Utilization of core wash material in the diagnosis of breast lesions by stereotactic needle biopsy. Cancer. 84(2):98-100, 1998
                                                                          45. Meechan J: How to avoid local anaesthetic toxicity. Br Dent J. 184(7):334-5, 1998
                                                                          46. Burbank F et al: Tissue marking clip for stereotactic breast biopsy: initial placement accuracy, long-term stability, and usefulness as a guide for wire localization. Radiology. 205(2):407-15, 1997
                                                                          47. Burbank F: Mammographic findings after 14-gauge automated needle and 14-gauge directional, vacuum-assisted stereotactic breast biopsies. Radiology. 204(1):153-6, 1997
                                                                          48. Fuhrman G et al: Stereotactic core needle breast biopsy is an accurate diagnostic technique to assess nonpalpable mammographic abnormalities. J La State Med Soc. 148(4):167-70, 1996
                                                                          49. Parker SH et al: Nonpalpable breast lesions: stereotactic automated large-core biopsies. Radiology. 180(2):403-7, 1991
                                                                          50. Lofgren M et al: Stereotactic fine-needle aspiration for cytologic diagnosis of nonpalpable breast lesions. AJR Am J Roentgenol. 154(6):1191-5, 1990
                                                                          51. Parker SH et al: Stereotactic breast biopsy with a biopsy gun. Radiology. 176(3):741-7, 1990