Diagnostic ultrasound ( PDFDrive )

812 PART III Small Parts, Carotid Artery, and Peripheral Vessel Sonography
FIG. 21.79 High-Grade Invasive Duct Carcinoma With Second
in Situ Lesion With Only “Soft” Finding at Presentation. (A) Targeted
diagnostic ultrasound shows an irregularly shaped mass that appeared
as a palpable lump. Ultrasound-guided biopsy showed high-grade invasive
ductal carcinoma. (B) Magnetic resonance imaging (MRI) shows an
ipsilateral nonmasslike area (arrow) of clumped enhancement farther
inferiorly that lies just inferior to a large cyst. (C) Second-look ultrasound
shows no mass. Only the soft indings of branching ducts and microcalciications
(within dotted box) next to a large, simple cyst correspond
to clumped enhancement on MRI. Ultrasound-guided vacuum biopsy
showed intermediate–nuclear-grade in situ carcinoma.
A
B L L
C
1 N7–8 ARAD
LT breast palp area
1 N1 Obliq
Left breast ques area on MRI
the target. his is most helpful for intraductal masses or complex
cystic masses, in which the cystic component is likely to disappear
ater initial sampling, making the target less visible with each
subsequent pass. Vacuum assistance can also be helpful for masses
containing calciications.
A marker should be placed ater every ultrasound-guided
biopsy. he reason is that if the biopsy reveals malignant or
atypical histology, a needle localization excisional biopsy will
frequently be necessary. his marker can be targeted by needle
localization when the area is ultimately surgical excised. In
addition, if the lesion is malignant, the patient may receive
chemotherapy before surgery. Ater chemotherapy, all imaging
evidence of the lesion may disappear, but the marker will continue
to denote the area of prior cancer. Finally, the presence of markers
placed in a benign lesion helps immensely in interpreting
follow-up mammograms. Future imagers will know that the area
has undergone biopsy and is benign.
Axillary lymph nodes can be sampled using ine-needle
aspiration with smaller-gauge needles, oten ranging from 22 to
25 gauge, or with core biopsy. he method of sampling is typically
chosen based on radiologist and pathologist preference. herapeutic
and diagnostic aspiration of cysts can be performed with
ine-needle aspiration, typically with a larger-gauge needle of 16
to 18 gauge. If the luid is thick, even larger-gauge needles may
be used, including the coaxial introducers from the biopsy device.
If the aspirate is benign appearing with colors including black,
green, yellow, and clear, then the luid can be discarded. If the
aspirate is bloody, then it should be sent to the cytology department
for analysis and a marker should be placed in the breast.
Should the aspirate be found to be atypical or malignant, the
marker is then present to guide future surgery.
he recommended technique for most procedures, but most
importantly for biopsies with devices that have a throw, is to
place the needle along the long axis of the transducer, enabling
the needle to be visualized along its entire course in real time
throughout the entire procedure. his is most important to ensure
that the biopsy device does not extend into the chest wall
musculature during sampling. he main diiculty encountered
during a long-axis approach is in keeping the needle and the
long axis of the transducer exactly parallel to each other. Watching
the ultrasound monitor before the needle has passed far enough
into the breast to be within the ultrasound beam is the main
cause of misalignment. It is best to watch one’s hands until the
needle is deep enough within the breast to be within the