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DOI: 10.1148/rg.271065029
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Missed Breast Cancers at US-guided Core Needle Biopsy: How to Reduce Them1

Ji Hyun Youk, MD, Eun-Kyung Kim, MD, Min Jung Kim, MD, Ji Young Lee, MD and Ki Keun Oh, MD

1 From the Department of Diagnostic Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seodaemun-ku, Shinchon-dong 134, Seoul 120-752, South Korea. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received March 17, 2006; revision requested May 26; final revision received September 5; accepted September 6. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Poor lesion visualization at US-guided biopsy performed with the multipass automated gun technique. (a) US image of the breast shows numerous echogenic specular reflectors (arrow) corresponding to clustered microcalcifications against a hypoechoic background. (b) On a US image obtained after the first pass of the core biopsy needle through the microcalcifications, bright hyperechoic air in the biopsy track (arrows) mimics and obscures the targeted microcalcifications.

 

Figure 1
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  		Figure 1b.  Poor lesion visualization at US-guided biopsy performed with the multipass automated gun technique. (a) US image of the breast shows numerous echogenic specular reflectors (arrow) corresponding to clustered microcalcifications against a hypoechoic background. (b) On a US image obtained after the first pass of the core biopsy needle through the microcalcifications, bright hyperechoic air in the biopsy track (arrows) mimics and obscures the targeted microcalcifications.

 

Figure 2
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  		Figure 2a.  Visualization of the core biopsy needle with respect to needle angle. (a) US image obtained with a steep angle between the ultrasound beam and the needle does not clearly depict the needle (arrow) due to the generation of fewer reflected echoes. (b) US image obtained with the needle perpendicular to the ultrasound beam allows optimal visualization of the needle (arrow).

 

Figure 2
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  		Figure 2b.  Visualization of the core biopsy needle with respect to needle angle. (a) US image obtained with a steep angle between the ultrasound beam and the needle does not clearly depict the needle (arrow) due to the generation of fewer reflected echoes. (b) US image obtained with the needle perpendicular to the ultrasound beam allows optimal visualization of the needle (arrow).

 

Figure 3
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  		Figure 3a.  Effect of needle placement during core needle biopsy. Drawings illustrate how a skin entry site close to the center of the breast (a) makes the biopsy needle angled, resulting in poor needle visualization, whereas inserting the needle at the periphery of the breast (b) allows the needle to be oriented parallel to the chest wall and perpendicular to the ultrasound beam.

 

Figure 3
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  		Figure 3b.  Effect of needle placement during core needle biopsy. Drawings illustrate how a skin entry site close to the center of the breast (a) makes the biopsy needle angled, resulting in poor needle visualization, whereas inserting the needle at the periphery of the breast (b) allows the needle to be oriented parallel to the chest wall and perpendicular to the ultrasound beam.

 

Figure 4
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  		Figure 4a.  Effect of gun positioning during core needle biopsy for a deep lesion. (a) Drawing illustrates that, when the gun is held rightside up, the needle must be angulated toward the chest wall. (b) Drawing illustrates that, with the gun flipped upside down, the lesion can be approached with the needle parallel to both the chest wall (for greater safety) and the transducer face (for better needle visualization).

 

Figure 4
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  		Figure 4b.  Effect of gun positioning during core needle biopsy for a deep lesion. (a) Drawing illustrates that, when the gun is held rightside up, the needle must be angulated toward the chest wall. (b) Drawing illustrates that, with the gun flipped upside down, the lesion can be approached with the needle parallel to both the chest wall (for greater safety) and the transducer face (for better needle visualization).

 

Figure 5
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  		Figure 5.  Drawings illustrate how misalignment of the core biopsy needle can be corrected by adjusting its position relative to the lesion. As shown in A, the long axis of the transducer should be aligned with the lesion and the skin incision site. Drawings B and C illustrate the proper technique, should the needle be advanced to the expected location of the lesion and the needle is not visualized in the field of view: In B, stop moving the needle, and in C, gently rock the transducer to localize the needle (1). In D, the needle is withdrawn slightly (2). In E, the orientation of the long axis of the transducer is corrected by aligning the lesion and the skin incision site (3) and moving the needle slightly toward the lesion (4). The needle should then be "walked" to the lesion (5) by using fine, delicate, and slow movements.

 

Figure 6
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  		Figure 6.  Approaching a deep lesion. Drawing illustrates how the biopsy needle is used to elevate the lesion away from the chest wall. The tip of the needle is wedged into the lesion and the gun-needle mechanism is levered down, thereby raising the needle and the lesion.

 

Figure 7
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  		Figure 7a.  Correlation of mammographic and US findings. Mammography performed at another hospital revealed fine, pleomorphic, clustered microcalcifications in the left breast. (a) US image reveals a cluster of tiny hyperechoic foci (arrowheads) in the left subareolar area. A BB marker was positioned on the skin overlying this cluster. (b) Left-sided coned compression magnification view shows a suspicious cluster of microcalcifications in the area of the BB marker. (c) Specimen mammogram obtained after US-guided biopsy shows the targeted microcalcifications (arrows), which were diagnosed as ductal carcinoma in situ.

 

Figure 7
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  		Figure 7b.  Correlation of mammographic and US findings. Mammography performed at another hospital revealed fine, pleomorphic, clustered microcalcifications in the left breast. (a) US image reveals a cluster of tiny hyperechoic foci (arrowheads) in the left subareolar area. A BB marker was positioned on the skin overlying this cluster. (b) Left-sided coned compression magnification view shows a suspicious cluster of microcalcifications in the area of the BB marker. (c) Specimen mammogram obtained after US-guided biopsy shows the targeted microcalcifications (arrows), which were diagnosed as ductal carcinoma in situ.

 

Figure 7
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  		Figure 7c.  Correlation of mammographic and US findings. Mammography performed at another hospital revealed fine, pleomorphic, clustered microcalcifications in the left breast. (a) US image reveals a cluster of tiny hyperechoic foci (arrowheads) in the left subareolar area. A BB marker was positioned on the skin overlying this cluster. (b) Left-sided coned compression magnification view shows a suspicious cluster of microcalcifications in the area of the BB marker. (c) Specimen mammogram obtained after US-guided biopsy shows the targeted microcalcifications (arrows), which were diagnosed as ductal carcinoma in situ.

 

Figure 8
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  		Figure 8a.  Confirmation of lesion penetration. (a) Prefire US image shows the relationship of the biopsy needle (arrow) to the lesion. (b) On a postfire US image, the needle (arrow) is seen penetrating through the lesion. (c) Orthogonal US image helps confirm that the needle (arrow) has penetrated the lesion.

 

Figure 8
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  		Figure 8b.  Confirmation of lesion penetration. (a) Prefire US image shows the relationship of the biopsy needle (arrow) to the lesion. (b) On a postfire US image, the needle (arrow) is seen penetrating through the lesion. (c) Orthogonal US image helps confirm that the needle (arrow) has penetrated the lesion.

 

Figure 8
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  		Figure 8c.  Confirmation of lesion penetration. (a) Prefire US image shows the relationship of the biopsy needle (arrow) to the lesion. (b) On a postfire US image, the needle (arrow) is seen penetrating through the lesion. (c) Orthogonal US image helps confirm that the needle (arrow) has penetrated the lesion.

 

Figure 9
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  		Figure 9a.  Proper positioning of the probe during US-guided directional vacuum-assisted core biopsy. (a) US image shows that the probe (small arrows) is posterior to the lesion, which is nevertheless within the limits of the probe aperture. The aperture can be clearly visualized owing to the discontinuity of the anterior wall of the probe and the ring-down artifact on the opposite side of the aperture (large arrows). (b) US image shows that the cutter (arrow) has been advanced through the lesion.

 

Figure 9
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  		Figure 9b.  Proper positioning of the probe during US-guided directional vacuum-assisted core biopsy. (a) US image shows that the probe (small arrows) is posterior to the lesion, which is nevertheless within the limits of the probe aperture. The aperture can be clearly visualized owing to the discontinuity of the anterior wall of the probe and the ring-down artifact on the opposite side of the aperture (large arrows). (b) US image shows that the cutter (arrow) has been advanced through the lesion.

 

Figure 10
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  		Figure 10a.  Appearance of the specimen in formalin. (a) Photograph shows a core sample that is yellow and floats on the surface of the formalin, findings that indicate that the sample is insufficient for diagnosis. (b) Photograph obtained in a different patient shows a core sample that is predominantly white and sinks in the formalin, findings that indicate that the sample is probably diagnostic.

 

Figure 10
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  		Figure 10b.  Appearance of the specimen in formalin. (a) Photograph shows a core sample that is yellow and floats on the surface of the formalin, findings that indicate that the sample is insufficient for diagnosis. (b) Photograph obtained in a different patient shows a core sample that is predominantly white and sinks in the formalin, findings that indicate that the sample is probably diagnostic.

 

Figure 11
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  		Figure 11a.  Radiologic-histologic discordance in a 36-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows an oval, ill-defined hypoechoic mass in the left breast that was graded as a BI-RADS category 4 lesion. (b) Postfire US image shows the mass. The histologic diagnosis was dense intralobular fibrosis and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 11
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  		Figure 11b.  Radiologic-histologic discordance in a 36-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows an oval, ill-defined hypoechoic mass in the left breast that was graded as a BI-RADS category 4 lesion. (b) Postfire US image shows the mass. The histologic diagnosis was dense intralobular fibrosis and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 12
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  		Figure 12a.  Radiologic-histologic discordance in a 41-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows a palpable, irregular, markedly hypoechoic mass in the left breast. The mass was graded as a BI-RADS category 4c lesion. (b) Postfire US image shows the mass. The histologic diagnosis was fibrocystic disease and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 12
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  		Figure 12b.  Radiologic-histologic discordance in a 41-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows a palpable, irregular, markedly hypoechoic mass in the left breast. The mass was graded as a BI-RADS category 4c lesion. (b) Postfire US image shows the mass. The histologic diagnosis was fibrocystic disease and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 13
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  		Figure 13a.  Radiologic-histologic discordance in a 41-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows an irregular, spiculated, markedly hypoechoic mass with posterior shadowing in the left breast. The mass was graded as a BI-RADS category 5 lesion. (b) Postfire US image shows the mass. The histologic diagnosis was fibrocystic disease with ductal epithelial hyperplasia and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 13
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  		Figure 13b.  Radiologic-histologic discordance in a 41-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows an irregular, spiculated, markedly hypoechoic mass with posterior shadowing in the left breast. The mass was graded as a BI-RADS category 5 lesion. (b) Postfire US image shows the mass. The histologic diagnosis was fibrocystic disease with ductal epithelial hyperplasia and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 14
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  		Figure 14a.  Radiologic-histologic discordance in a 65-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows an irregular, ill-defined hypo-echoic mass in the right breast (arrows) that was graded as a BI-RADS category 5 lesion. (b) Postfire US image shows the mass. The histologic diagnosis was ductal epithelial hyperplasia and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 14
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  		Figure 14b.  Radiologic-histologic discordance in a 65-year-old woman with invasive ductal carcinoma. US-guided 14-gauge core needle biopsy was performed. (a) Prefire US image shows an irregular, ill-defined hypo-echoic mass in the right breast (arrows) that was graded as a BI-RADS category 5 lesion. (b) Postfire US image shows the mass. The histologic diagnosis was ductal epithelial hyperplasia and was considered discordant with the US findings. Surgical excision was performed immediately, and the mass was diagnosed as invasive ductal carcinoma.

 

Figure 15
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  		Figure 15a.  Invasive ductal carcinoma in a 60-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a focal asymmetry in the right breast (arrow). Note also the circumscribed, hyperdense nodule in the outer portion of the left breast (arrowhead), a finding that represents a benign cyst. (b) US image shows an ill-defined hypoechoic lesion with a geographic pattern in the upper medial portion of the right breast corresponding to the focal asymmetry seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. Two years later, the patient presented with a palpable lump. (c) Craniocaudal mammogram shows a round, ill-defined hyperdense mass (arrow) corresponding to the earlier imaging findings (cf a, b). (d, e) US images reveal a palpable, 1.5-cm cystic mass with irregular wall thickening and increased blood flow in the upper medial portion of the right breast. Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 15
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  		Figure 15b.  Invasive ductal carcinoma in a 60-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a focal asymmetry in the right breast (arrow). Note also the circumscribed, hyperdense nodule in the outer portion of the left breast (arrowhead), a finding that represents a benign cyst. (b) US image shows an ill-defined hypoechoic lesion with a geographic pattern in the upper medial portion of the right breast corresponding to the focal asymmetry seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. Two years later, the patient presented with a palpable lump. (c) Craniocaudal mammogram shows a round, ill-defined hyperdense mass (arrow) corresponding to the earlier imaging findings (cf a, b). (d, e) US images reveal a palpable, 1.5-cm cystic mass with irregular wall thickening and increased blood flow in the upper medial portion of the right breast. Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 15
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  		Figure 15c.  Invasive ductal carcinoma in a 60-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a focal asymmetry in the right breast (arrow). Note also the circumscribed, hyperdense nodule in the outer portion of the left breast (arrowhead), a finding that represents a benign cyst. (b) US image shows an ill-defined hypoechoic lesion with a geographic pattern in the upper medial portion of the right breast corresponding to the focal asymmetry seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. Two years later, the patient presented with a palpable lump. (c) Craniocaudal mammogram shows a round, ill-defined hyperdense mass (arrow) corresponding to the earlier imaging findings (cf a, b). (d, e) US images reveal a palpable, 1.5-cm cystic mass with irregular wall thickening and increased blood flow in the upper medial portion of the right breast. Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 15
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  		Figure 15d.  Invasive ductal carcinoma in a 60-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a focal asymmetry in the right breast (arrow). Note also the circumscribed, hyperdense nodule in the outer portion of the left breast (arrowhead), a finding that represents a benign cyst. (b) US image shows an ill-defined hypoechoic lesion with a geographic pattern in the upper medial portion of the right breast corresponding to the focal asymmetry seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. Two years later, the patient presented with a palpable lump. (c) Craniocaudal mammogram shows a round, ill-defined hyperdense mass (arrow) corresponding to the earlier imaging findings (cf a, b). (d, e) US images reveal a palpable, 1.5-cm cystic mass with irregular wall thickening and increased blood flow in the upper medial portion of the right breast. Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 15
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  		Figure 15e.  Invasive ductal carcinoma in a 60-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a focal asymmetry in the right breast (arrow). Note also the circumscribed, hyperdense nodule in the outer portion of the left breast (arrowhead), a finding that represents a benign cyst. (b) US image shows an ill-defined hypoechoic lesion with a geographic pattern in the upper medial portion of the right breast corresponding to the focal asymmetry seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. Two years later, the patient presented with a palpable lump. (c) Craniocaudal mammogram shows a round, ill-defined hyperdense mass (arrow) corresponding to the earlier imaging findings (cf a, b). (d, e) US images reveal a palpable, 1.5-cm cystic mass with irregular wall thickening and increased blood flow in the upper medial portion of the right breast. Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 16
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  		Figure 16a.  Invasive ductal carcinoma in a 53-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a small, isodense nodule in the left breast (arrow). (b) US image shows an ill-defined hypoechoic lesion (arrow) corresponding to the nodule seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. (c, d) Follow-up mammogram (c) and US image (d) obtained 6 months later show an interval increase in the size of the nodule (arrow in c). Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 16
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  		Figure 16b.  Invasive ductal carcinoma in a 53-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a small, isodense nodule in the left breast (arrow). (b) US image shows an ill-defined hypoechoic lesion (arrow) corresponding to the nodule seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. (c, d) Follow-up mammogram (c) and US image (d) obtained 6 months later show an interval increase in the size of the nodule (arrow in c). Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 16
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  		Figure 16c.  Invasive ductal carcinoma in a 53-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a small, isodense nodule in the left breast (arrow). (b) US image shows an ill-defined hypoechoic lesion (arrow) corresponding to the nodule seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. (c, d) Follow-up mammogram (c) and US image (d) obtained 6 months later show an interval increase in the size of the nodule (arrow in c). Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 

Figure 16
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  		Figure 16d.  Invasive ductal carcinoma in a 53-year-old woman. The cancer was missed at US-guided core biopsy but was detected at mammographic-US follow-up. (a) Craniocaudal mammogram shows a small, isodense nodule in the left breast (arrow). (b) US image shows an ill-defined hypoechoic lesion (arrow) corresponding to the nodule seen at mammography (cf a). The lesion was graded as a BI-RADS category 4a lesion, and biopsy was performed. The histologic diagnosis was fibrocystic disease and was considered concordant with the imaging findings. (c, d) Follow-up mammogram (c) and US image (d) obtained 6 months later show an interval increase in the size of the nodule (arrow in c). Biopsy was performed, and the lesion was diagnosed as invasive ductal carcinoma.

 




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