MRI-Guided Breast Biopsy
Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous.
A breast biopsy is performed to remove some cells—either surgically or through a less invasive procedure involving a hollow needle—from a suspicious area in the breast and examine them under a microscope to determine a diagnosis. Image-guided needle biopsy is not designed to remove the entire lesion, but most of a very small lesion may be removed in the process of biopsy.
Image-guided biopsy is performed when the abnormal area in the breast is too small to be felt, making it difficult to locate the lesion by hand (called palpation).
In MRI-guided breast biopsy, magnetic resonance imaging is used to help guide the radiologist’s instruments to the site of the abnormal growth.
Why is this procedure conducted?
An MRI-guided breast biopsy is most helpful when MR imaging shows a breast abnormality such as:
- A suspicious mass not identified by other imaging techniques
- An area of distortion
- An area of abnormal tissue change
MRI guidance is used in four biopsy procedures:
- Fine needle aspiration (FNA), which uses a very small needle to extract fluid or cells from the abnormal area.
- Core needle (CN) which uses a large hollow needle to remove one sample of breast tissue per insertion.
- Vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion.
- Wire localization, in which a guide wire is placed into the suspicious area to help the surgeon locate the lesion for surgical biopsy.
How do I prepare for the exam?
You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing if it is loose-fitting and has no metal fasteners.
Guidelines about eating and drinking before an MRI exam vary with the specific exam and also with the facility. Unless you are told otherwise, you may follow your regular daily routine and take medications as usual.
Some MRI examinations may require the patient receive an injection of contrast into the bloodstream. The radiologist or technologist may ask if you have allergies of any kind, such as allergy to iodine or x-ray contrast material, drugs, food, the environment, or asthma. However, the contrast material used for an MRI exam does not contain iodine and is less likely to cause an allergic reaction.
The radiologist should also know if you have any serious health problems and what surgeries you have undergone. Some conditions, such as severe kidney disease may prevent you from having an MRI with contrast material.
Women should always inform their physician or technologist if there is any possibility that they are pregnant. MRI has been used for scanning patients since the 1980's with no reports of any ill effects on pregnant women or their babies. However, because the baby will be in a strong magnetic field, pregnant women should not have this exam unless the potential benefit from the MRI is assumed to outweigh the potential risks.
Prior to a needle biopsy, you should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia. Your physician will advise you to stop taking aspirin or a blood thinner three days before your procedure.
Also, inform your doctor about recent illnesses or other medical conditions.
You may want to have a relative or friend accompany you and drive you home afterward. This is recommended if you have been sedated.
What type of equipment is used?
The traditional MRI unit is a large cylinder-shaped tube surrounded by a circular magnet. You will lie on a moveable examination table that slides into the center of the magnet.
The computer workstation that processes the imaging information is located in a separate room than the scanner.
The majority of MRI-guided breast biopsies are currently performed in closed MRI systems with a specially modified exam table. This moveable examination table allows your breasts to hang freely into cushioned openings, which contain wire coils that send and receive radio waves to help create the MR images.
One of four instruments will be used:
- A fine needle attached to a syringe, smaller than needles typically used to draw blood.
- A core needle, also called an automatic, spring-loaded needle, which consists of an inner needle connected to a trough, or shallow receptacle, covered by a sheath and attached to a spring-loaded mechanism.
- A vacuum-assisted device (VAD), a vacuum-powered instrument that uses pressure to pull tissue into the needle.
- A thin guide wire, which is used for a surgical biopsy.
Other sterile equipment involved in this procedure includes syringes, sponges, forceps, scalpels and a specimen cup or microscope slide.
How is the procedure performed?
Image-guided, minimally invasive procedures such as MR-guided breast biopsies are most often performed by a specially trained breast radiologist.
Breast biopsies are usually done on an outpatient basis.
You will lie face down on a moveable exam table and the affected breast or breasts will be positioned into openings in the table.
A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm and the contrast material will be given intravenously.
Your breast will be gently compressed between two compression plates (similar to those used in a diagnostic MRI exam), one of which is marked with a grid structure. Using computer software, the radiologist measures the position of the lesion with respect to the grid and calculates the position and depth of the needle placement.
A local anesthetic will be injected into the breast to numb it.
A very small nick is made in the skin at the site where the biopsy needle is to be inserted.
The radiologist then inserts the needle, advances it to the location of the abnormality and MR imaging is performed to verify its position. Depending on the type of MRI unit being used, you may remain in place or be moved out of the center or bore of the MRI scanner.
Tissue samples are then removed using one of three methods:
- In a fine needle aspiration, a fine gauge needle and a syringe withdraw fluid or clusters of cells.
- In a core needle biopsy, the automated mechanism is activated, moving the needle forward and filling the needle trough, or shallow receptacle, with 'cores' of breast tissue. The outer sheath instantly moves forward to cut the tissue and keep it in the trough. This process is repeated three to six times.
- With a vacuum-assisted device (VAD), vacuum pressure is used to pull tissue from the breast through the needle into the sampling chamber. Without withdrawing and reinserting the needle, it rotates positions and collects additional samples. Typically, eight to 10 samples of tissue are collected from around the lesion.
After this sampling, the needle will be removed.
If a surgical biopsy is being performed, a wire is inserted into the suspicious area as a guide for the surgeon.
A small marker may be placed at the site so that it can be located in the future if necessary.
Once the biopsy is complete, pressure will be applied to stop any bleeding and the opening in the skin is covered with a dressing. No sutures are needed.
A mammogram may be performed to confirm that the marker is in the proper position.
This procedure is usually completed within 45 to 60 minutes.
What can I expect during the exam?
You will be awake during your biopsy and should have little or no discomfort. Most women report little or no pain and no scarring on the breast.
Some women find that the major discomfort of the procedure is from lying on their stomach for the length of the procedure, which can be reduced by strategically placed cushions.
When you receive the local anesthetic to numb the skin, you will feel a slight pin prick from the needle. You may feel some pressure when the biopsy needle is inserted.
The area will become numb within a short time.
You must remain still while the biopsy is performed.
As tissue samples are taken, you may hear clicks from the sampling instrument.
If you experience swelling and bruising following your biopsy, you may be instructed to take an over-the-counter pain reliever and to use a cold pack. Temporary bruising is normal.
You should contact your physician if you experience excessive swelling, bleeding, drainage, redness or heat in the breast.
If a marker is left inside the breast to mark the location of the biopsied lesion, it will cause no pain, disfigurement or harm.
You should avoid strenuous activity for 24 hours after returning home, but then usually will be able to resume normal activities.
It is recommended that nursing mothers not breastfeed for 36 to 48 hours after an MRI with a contrast material.
What can I expect after the exam?
A pathologist examines the removed specimen and makes a final diagnosis. Depending on the facility, the radiologist or your referring physician will share the results with you.