There are multiple imaging modalities utilized in diagnosing disease of the breast. The goal of diagnostic imaging and biopsy, is to utilize the least invasive technique to make a definitive diagnosis.
From screening to diagnostic imaging, there are multiple modalities, whereby the breast can be imaged & biopsied. Not all are indicated. Deciding what is the correct test, is paramount to making the correct diagnosis.
The most critical part of making a diagnosis, is determining the appropriate testing needed. Just because there ‘is a test’ doesn’t mean it is necessary. The right test for the right patient is paramount to high quality care.
The “gold standard”. Screening mammography remains the best method to screen the breast. Typically, screening studies involve two views of each breast, and look for symmetry, masses, and calcifications. Like all early detection strategies, screening mammography involves trade-offs. Understanding these trade-offs is imperative in joint decision making as to when and in whom screening mammography should be performed.
Breast ultrasound is an adjunct to physical exam, mammograms, and ultrasounds. Typically, ultrasound is not a screening test, however, there are ongoing Clinical Trials evaluating it’s use in this context. Ultrasound guided biopsies/aspirations are done, typically on the same day as an office visit, using local anesthetic. Expediting diagnosis in this manner, hopefully can reduce some of the anxiety caused by having an abnormal study. In addition, those women with a new mass/lump, may have a same day ultrasound, in order to better direct the next step in diagnosis and care.
Magnetic resonance imaging (MRI) is a noninvasive medical test. MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce a detailed picture of the breast. MRI does not use ionizing radiation (x-rays). Breast MRI requires the injection of a ‘dye’ gadolinium intravenously to help generate the multiple pictures of the breast. What is a little peculiar, is that when the test is being performed, women lie prone (face down). Both breasts are imaged. The test typically takes 30-45 minutes.
Once an abnormality is identified in the breast, the next step is obtaining a tissue diagnosis. A tissue diagnosis will allow a treatment plan to formulate. In the past, all biopsies of the breast were done surgically. Today, the standard has changed.
Whenever possible, diagnosis of breast lesions should be performed with a needle, rather than a surgical procedure. When a lesion is seen with ultrasound, this modality should be used for image-guidance. Image-guidance is an extremely useful adjunct in the performance of percutaneous biopsy of palpable breast lesions. Image-guidance confirms the proper placement of the biopsy device into the lesion (when core needle device is used), or immediately below the lesion (when vacuum-assisted device is used). Performing percutaneous breast biopsy procedures without the use of image-guidance may lead to false negative results since the biopsy device cannot be confirmed to be in the proper position to obtain tissue from the suspect mass. In most, if not all instances of image-guided biopsy of palpable breast lesions, ultrasound is the preferred image-guidance modality.
When a lesion is visible by ultrasound, this modality is used to localize the lesion, and, guide biopsy. Ultrasound guided procedures are well tolerated. This procedure can be done in the office, typically, on the same day as the office visit.
A stereotactic core biopsy, is a technique whereby a lesion that is visualized mammographically, can undergo biopsy, using mammographically (stereotactic) guided biopsy techniques. This again, follows the recommendation of using a needle to make the diagnosis of a breast lesion. Stereotactic core biopsies, are performed when a lesion is visible by mammogram only.