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508
V. Kubihal et al.
41.5 Cordocentesis andFetal Blood
Transfusion
Cordocentesis, also called as percutaneous umbilical cord
blood sampling, is a method of obtaining fetal blood by placing a thin needle in the umbilical vein close to the placental
insertion site, under ultrasound guidance [13, 14]. Apart from
diagnostic blood sampling, it can also be used for administering medications and intrauterine blood transfusions [15].
41.5.1 Indications [15–19]
1) Diagnosis and treatment of severe fetal anemia—most
common indication.
2) Diagnosis of neonatal alloimmune thrombocytopenia.
Cordocentesis can also be used for response assessment
following maternal intravenous immunoglobulin administration; however, it is generally not recommended when
vaginal delivery is not under consideration.
3) Evaluation of non-immune fetal hydrops—when maternal
serum markers, ultrasound evaluation, and amniocentesis
are negative, and middle cerebral artery PSV is elevated.
4) Historical or rare indications include:
• Karyotyping in suspected fetal aneuploidy.
• Diagnosis of genetic disorders such as thalassemia,
hemophilia, etc.
• Identication of fetal blood type and platelet antigen.
• Serum markers for various fetal diseases such as fetal
infection and fetal thyroid function.
• Administration of medication, for example, in fetal
supraventricular tachycardia, when maternal systemic
therapy fails.
41.5.2 Contraindications [20–23]
There are no absolute contraindications. Relative contraindications include:
1) Certain maternal viral infections including human immunodeciency virus infection and hepatitis virus, due to the
theoretical risk of vertical transmission.
2) Early gestation age, due to greater technical difculty,
and increased complication rate.
perform in an operation theatre, or a room close to it,
should the need for emergency cesarean delivery arise.
Prophylactic steroids can be considered prior to the procedure if cordocentesis is performed between 24 and
34weeks of gestation.
• Strict aseptic precautions are to be followed including
antibacterial preparation of skin.
• The procedure is commonly performed under local
anesthesia.
• Ultrasound guidance is used.
• The procedure can be performed with either freehand
technique or using a needle guide.
• Often, a 20 or 22G lumbar puncture needle is used. The
gauge and length of the needle used can vary with the
maternal body habitus, gestational age, and distance of
the target from the skin.
• Sampling sites—Common sampling sites of the umbilical
vein used include:
– Placental insertion site—most commonly used tech-
nique. It allows stable needle access, especially when
the placenta is placed anteriorly. However, there is a
risk of contamination of maternal blood. Fetal origin
can be conrmed by high mean corpuscular volume, or
Kleihauer Betke test.
– Free loop of umbilical cord.
– Abdominal insertion site.
– Intrahepatic vein—intrahepatic segment of umbilical
vein or left portal vein is accessed.
Umbilical artery puncture should be avoided, as this may
cause vasoconstriction and fetal bradycardia.
• Some authors advise using heparin following access into
the umbilical vein, prior to fetal blood sampling, to prevent clot at the access site.
• Paralytic agents such as pancuronium, atracurium, and
vecuronium are generally recommended when largevolume paracentesis is required or when excess fetal
motion makes the procedure difcult. It is generally not
advised when cordocentesis is done for diagnostic purposes, or when placenta and cord insertion are anterior.
• In case of fetal anemia, blood is sent for assessment of
hemoglobin level or hematocrit, to decide the amount of
blood required for intrauterine transfusion.
• Once fetal blood sampling or intrauterine transfusion is
over, the needle is withdrawn.
• During the procedure, the fetal heart can be intermittently
evaluated by direct ultrasound evaluation.
41.5.3 Technique [15, 23]
• There is insufcient evidence to recommend the routine
use of prophylactic antibiotics prior to cordocentesis.
• There is no consensus regarding where to perform the
procedure, whether in an ultrasound room, clinic, or an
operation theatre. But, it is generally recommended to
41.5.4 Complications [15, 23, 24]
• Access site bleed—seen in nearly 20–30% of cases.
Usually self-limited.
• Vertical transmission of maternal infection—limited data
on estimated risk.
41 Female Genital Tract andObstetric Interventions
509
• Abnormal fetal heart rate—bradycardia can be seen in
nearly 5–10% of cases, often transient, and resolve in
5min.
• Pregnancy loss is seen in 1.3% of patients. It can be higher
if there are associated fetal hydrops, structural fetal anomalies, severe growth restriction, or placental penetration.
• Other complications include amniotic uid infection, premature rupture of membranes, preterm labor, placental
abruption, and alloimmunization.
41.5.5 Outcome [23]
Technical success is high in experienced hands (~97–98.5%).
The survival rate after intrauterine transfusion for fetal alloimmunization depends on gestation age at rst presentation
and the presence and severity of fetal hydrops, and generally
is between 80 and 95%.
41.6 Selective Fetal Reduction inTwin
Pregnancy
Monochorionic twins can be associated with unique angioarchitecture characterized by connections between the vasculature of both fetuses, with net dynamic bidirectional blood
ow between fetuses. This can lead to complications that are
unique to monochorionic twins and include twin-twin transfusion syndrome, twin reverse arterial perfusion sequence,
severe intra-uterine growth restriction, and severe discordant
twins. In many circumstances, particularly when there is
impending fetal death of one twin, selective fetal termination
of the abnormal twin may be required, to increase the chances
of survival of the normal twin [25–28].
Selective intravascular potassium chloride injection into
abnormal twins is not recommended in monochorionic pregnancy, as there is a chance of embolization into normal twins
through existing vascular connections [26]. Also, acute
exsanguination of the normal twin can occur in the dead twin
through patent vascular connections [26]. Therefore, selective feticide of the abnormal twin in monochorionic pregnancy is performed through selective and complete occlusion
of the umbilical cord which cuts off blood supply to the
abnormal twin and also prevents exsanguination of the normal twin through placental vascular connections [26].
Common methods of umbilical cord occlusion include
bipolar cord coagulation, laser cord coagulation, cord ligation, and radiofrequency cord ablation (RFA) [25–27].
Bipolar cord occlusion has been the suggested gold standard
procedure for umbilical cord occlusion [26]. However, bipolar cord coagulation, laser cord coagulation, and cord liga-
tion require the insertion of large diameter operating
instruments through the bore of 3.8 mm operative sleeve,
which is associated with a higher risk of premature rupture
of membranes, bleeding complication, and preterm labor
[25]. Radiofrequency ablation (RFA) or microwave ablation
(MWA) is a relatively new, less invasive technique that can
be performed using smaller access (17 gauge or 1.4 mm
probe) to ablate the umbilical cord by generating high temperatures at the site of application [27, 29]. Although there is
a decrease in premature rupture of the membrane with RFA,
it is associated with a lower overall survival rate of normal
twin [27], probably related to the longer duration RFA takes
to stop blood ow in the umbilical cord which exposes normal twin to longer duration altered hemodynamics, compared to umbilical cord coagulation that causes more
instantaneous, and complete blood ow cessation. Thus, the
goal of RFA should be rapid application of high temperature
to achieve quicker, and complete coagulation [25].
41.6.1 Technique
To reduce the risk of procedure-related pregnancy loss, oral
indomethacin may be given prior to the procedure. The procedure is performed with the patient in supine position. The
abdomen is cleaned and draped. Local anesthesia is given
along with conscious sedation. Under continuous USG guidance, the RFA probe is inserted percutaneously, through the
uterus, into the abdominal segment of the umbilical cord of
abnormal fetus. Care is taken to avoid the placenta and amniotic sac of normal twin. It is recommended that the RFA
probe should be placed at least 1 cm from the area not
intended to ablate. Once the RFA probe is centered within
the abdominal segment of the umbilical cord, across the
umbilical vein (target vessel), radiofrequency energy is
applied with a diameter range of ~2 cm, and temperature
reaching up to 100–110 °C for the duration of 1–3 mins.
USG/Doppler is performed to conrm the cessation of blood
ow within the umbilical cord and to conrm cardiac asystole of the target fetus. USG can be performed 24h post procedure, to evaluate surviving normal fetus, placenta, and
amniotic uid volume [30–32].
41.6.2 Complications
Serious maternal complications are rare and can include chorioamnionitis, sepsis, hemorrhage, bodily injury, and maternal death. Fetal complications include thermal injury to
normal surviving twin, fetal demise of co-twin, premature
rupture of membrane, and preterm labor [31, 32].
510
V. Kubihal et al.
41.7 Fetoscopic Laser Ablation (FLA)
ofPlacental Anastomosis
Twin-twin transfusion syndrome (TTTS) is a unique complication of monochorionic pregnancy, where unidirectional
inter-fetal transfusion through placental vascular anastomosis results in oligohydramnios in the donor twin, and polyhydramnios in the recipient twin. Fetoscopic laser ablation
(FLA) of causative anastomotic vessels is the treatment of
choice for TTTS [33, 34].
Non-selective FLA involves ablation of all the vessels
that cross the intertwin membrane. This technique was associated with high procedure-related fetal loss of 15–50%,
probably related to ablation of normal chorionic vessels at
the intertwin membrane in addition to culprit anastomotic
vessels [34]. Selective FLA involves precise and selective
ablation of anastomotic vessels at the intertwin membrane.
Selective FLA is associated with lower rate of fetal loss of
~5.6% [33]. Sequential selective FLA involves precise and
selection ablation of placental anastomoses in an orderly
manner starting with donor-to-recipient arterio-venous anastomoses, followed by donor-to-recipient veno-arterial anastomoses, and then uncommon arterio-arterial and
veno-venous anastomoses. In comparison with selective
FLA, sequential selective FLA is associated with reduction
in fetal loss by 50–60% [33]. Solomon technique is a relatively new technique where in addition to selective or sequential selective FLA, supercial ablation of the placental
vascular equator is done, thus clinically dechorionizing the
placenta. The placental vascular equator is dened as an
imaginary plane drawn mid-way and perpendicular to the
line joining the placental cord insertion of both the twins
[35]. This technique reduced the recurrence of TTTS, and
twin reverse arterial perfusion sequence following primary
laser ablation in TTTS [33, 36].
ered a relative contraindication for FLA, due to large intertwin anastomotic vessels directly arising from the umbilical
cord [33].
FLA is often performed as an outpatient procedure. The
patient is placed in supine position. The patient’s abdomen is
cleaned and draped. The procedure is performed under local
anesthesia and conscious sedation. After USG mapping, a
fetoscope is introduced through the maternal abdomen into
the recipient’s amniotic sac, at the site where it provides the
best access to the placental vascular equator. A 10–12G cannula is introduced percutaneously or through minilaparotomy, under continuous USG guidance. This provides
access to a 2–3.6mm fetoscope. Once inside the recipient’s
amniotic sac, both the fetuses are inspected for any gross
malformation or discordant pallor. The intertwin membrane
is then identied, and vessels are traced back to origin from
the intertwin membrane to identify and conrm anastomotic
vessels. Selective ablation of anastomotic vessels is done at
intertwin membrane using 400–650mm laser ber (20–40W
with ND-YAG or diode laser). In addition, the Solomon technique is often performed where supercial laser ablation of
the placental vascular equator is also ablated. Once the ablation is completed, amnioreduction of the recipient is often
done to normalize amniotic uid volume [33].
41.7.3 Complications
Periprocedural complications are common following
FLA.Premature rupture of the membrane is the most common complication seen in over 30% of cases before 34weeks.
Chorio-amnion separation is seen in more than 20% of cases.
Other complications include amniotic uid leak (seen in
~7% of cases), vaginal bleed (in ~4% of cases), abruption (in
~2% of cases), chorioamnionitis (in ~2% of cases), and constrictive amniotic bands (2%) [33].
41.7.1 Contraindications
FLA is contraindicated in patients with active vaginal bleeding, sub-chorionic hematoma, chorio-amnion separation,
preterm premature rupture of membrane, and active labor.
Short cervix and TTTS with discordant malformed twins are
considered relative contraindications at certain centers [33].
41.7.2 Technique
Preprocedural USG can be done to identify the placental
cord insertion site. Short distance of <5cm between the cord
insertion sites of both twins is associated with a technically
more difcult procedure. And distance of <1cm is consid-
41.8 Thoracocentesis andThoracoamniotic
Shunt
Large pleural effusion, or cystic intrathoracic lesion, can be
associated with lung hypoplasia and sometimes fetal
hydrops. Thoracocentesis and thoracoamniotic shunt allow
lung re-expansion in these patients, and appropriate lung
development [28, 37, 38]. Primary hydrothorax is often chylous in nature and can be managed with thoracocentesis and
thoracoamniotic shunt. The procedure is usually performed
in the second trimester, up to 32 weeks of gestation.
Secondary hydrothorax, which occurs in fetal hydrops, is
often bilateral, and is not an indication for intervention [28,
37–40].
41 Female Genital Tract andObstetric Interventions
511
41.8.1 Technique
The procedure is often done under maternal local or epidural anesthesia. Intramuscular injection of vecuronium can
be used to reduce fetal movement during the procedure.
Prophylactic antibiotic use can be considered. The access
site is cleaned and draped. An 18G 20cm needle is used to
enter the fetal thorax. Ultrasound guidance and transabdominal transuterine approach are used. Care to be taken to
avoid the placenta and umbilical cord. Thoracoamniotic
shunt can be placed in the initial setting, or on follow-up if
there is rapid reaccumulation. Often, thoracocentesis is performed initially. After the lung expands, the underlying fetal
chest is to be evaluated for any lung abnormality. The fetus
should be evaluated after 1–3days, to look for rapid reaccumulation of pleural effusion, if present, thoracoamniotic
shunt can be considered. After needle access into the thoracic cavity, stiff/rosen wire is introduced into the thoracic
cavity. A 6f peel- away sheath can be placed to allow stable
access during the procedure. A double pigtail catheter can
be with one tip in the fetal pleural effusion and another in
the amniotic uid. This allows continuous decompression of
pleural uid into amniotic uid. Color Doppler can be used
to access the ow of uid across the shunt. Over several
minutes, drainage of fetal uid was accessed, and the return
of the fetal heart position to midline was conrmed. The
mother is called for weekly follow-up, and is accessed by
ultrasonography or MRI for shunt function, and fetus health
[28, 37, 39–41].
41.8.2 Complications
• Fetal hemothorax—seen an echogenic content with pleural uid.
• Re-accumulation of fetal hydrothorax.
• Mispositioned, dislodged, or blocked shunt—Dislodged
shunt is typically within the amniotic cavity, and need not
be retrieved prior to delivery [28, 37, 39–41].
41.9.1 Technique
The procedure is often done under maternal local or epidural
anesthesia. Intramuscular injection of vecuronium can be
used to reduce fetal movement during the procedure.
Prophylactic antibiotic use can be considered. The access
site is cleaned and draped. An 18G 20cm needle is used to
enter the fetal thorax. Ultrasound guidance and transabdominal transuterine approach is used. Care to be taken to avoid
placenta and umbilical vessels. Umbilical arteries can be
seen to course along the lateral bladder wall. Vesicocentesis
is performed to decompress the urinary bladder. Serial vesicocentesis is done to assess renal function and urine production. If salvageable renal function is identied, bladder
decompression should be considered. A double pigtail catheter can be with one tip in the urinary bladder and another in
the amniotic uid. This allows continuous decompression of
the urinary bladder into amniotic uid. Color Doppler can be
used to access the ow of uid across shunt. Simultaneous
amnio-infusion can be considered in the case of severe oligohydramnios [28, 37, 42, 43].
41.9.2 Complications [28, 44, 45]
• Hemorrhage.
• Mispositioned or dislodged shunt. Sometimes, the amniotic end of the shunt may get retracted into the fetal abdomen and can lead to urinary ascites.
• Long-term outcome.
– Vesicoamniotic shunt can interfere with bladder func-
tion leading to spastic urinary bladder, vesicoureteric
reux, and hydroureteronephrosis.
– Although vesicoamniotic shunt is seen to improve
amniotic uid volume, and pulmonary function, the
effect on improvement of renal function is marginal.
Most children will eventually require dialysis and
renal transplantation.
41.9 Vesicocentesis andVesicoamniotic
Shunt
The common cause of lower urinary tract obstruction is the
posterior urethral valve in males, and rarely, can be due to
urethral atresia. It is associated with overdistended bladder
and bilateral hydroureteronephrosis. Untreated lower urinary
tract obstruction can lead to irreversible renal damage, and
oligohydramnios that can cause fetal lung hypoplasia.
Vesicocentesis and vesicoamniotic shunt help to decompress
the high-pressure urinary system and allow accumulation of
amniotic uid [28, 37, 42, 43].
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Breast Interventions: Biopsy
andLocalization Techniques
EktaDhamija, PalakBhaveshPopat, andAnjumSyed
42
Key Messages
1. Image-guided breast interventions have become an integral component of management protocol.
2. It majorly includes breast biopsy and preoperative lesion
localization in order to guide surgical planning.
3. Unlike the rest of body, tissue sampling from breast
lesions is performed using 14G core biopsy needle.
4. Although vacuum-assisted biopsy is as accurate as surgical biopsy, it has been reserved for selective indications due to its higher cost and limited availability.
5. The role of radiologist extends beyond conducting
biopsy and extends to verify radiological and pathological concordance which can affect the treatment plan.
6. Lesion localization assists the surgeon in the accurate
removal of tissue which is not clinically palpable.
7. Most commonly localization is done with hookwire on
the same day as surgery and therefore needs close communication between radiologists and surgeons.
8. Specimen radiograph of biopsy cores especially in case
of microcalcication and post-wire tumour excision is
an inevitable step to conrm appropriate targeting and
adequate tissue removal.
9. Radiological breast interventions would also include targeted axillary nodal dissection, guide catheter placement
for partial breast irradiation, palliative interventions for
pain management, etc.
10. These interventions are minimally invasive and have signicant role in patient management.
E. Dhamija (*)
Department of Radiodiagnosis and Intervention Radiology,
IRCH, All India Institute of Medical Sciences, New Delhi, India
P. B. Popat
Department of Radiology, Tatal Memorial Hospital, Mumbai, India
A. Syed
Department of Radiodiagnosis, All India Institute of Medical
Sciences, Rishikesh, India
e-mail: anjum.rd@aiimsrishikesh.edu.in
42.1 Introduction
Over the last few decades, we have witnessed a rapid increase
in the incidence of breast cancer with variable outcomes in
associated morbidity and mortality. Appropriate biopsy technique for adequate sampling and good histopathological correlation is an integral component of early detection of breast
cancer. Imaging has become an inevitable component of the
diagnosis and management algorithm for these patients. The
treatment depends largely on the histopathological diagnosis
and classication depending on the receptor status for the
particular subtype. The milieu in breast parenchyma is under
constant inuence of hormonal changes, leading to physiological changes in development, proliferation, and involution
along with a plethora of benign and hyperplastic cellular
lesions. The thickness and adequacy of tissue core inuences
the effectiveness of pathological evaluation. Image guidance
offers real-time visualization of the biopsy needle and facilitates accurate tissue sampling. USG also enables the radiologist to distinguish solid from cystic components of the
masses. Unfortunately, in resource constraint settings,
palpation- guided biopsies are routinely performed for breast
masses and are associated with high false negative rates and
repeat biopsy rates.
In addition to the percutaneous biopsies, a dedicated
interventional radiology setup is crucial for preoperative
localization in non-palpable breast lesions and in cancers
showing complete/near complete clinical response after chemotherapy. This chapter aims to highlight these elds where
imaging has become an inseparable part of the management
protocol.
42.2 Breast Biopsy
42.2.1 Imaging Modality andLesion Selection
The logical rule is to target a lesion on the modality that
demonstrates the lesion best—it can be USG, mammogram
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(MG), or MRI.It thus becomes important to select the appropriate lesion and modality for performing biopsy. The
American College of Radiology (ACR) lexicon suggests that
the lesions with morphological appearance falling in
BI-RADS categories 4 and 5 need to be sampled to rule out
malignancy. BI-RADS category 3 lesions can also be
sampled if the patient or the physician is apprehensive or in
patients with another primary malignancy that is prone to
metastasize to the breast.
42.2.2 USG-Guided Biopsy [1, 2]
Unlike other body parts, breast biopsy is performed using a
14G automatic biopsy needle in routine practice, and 4–5
tissue cores are obtained for pathological evaluation. Nonimage guided biopsy may be performed for large palpable
masses, but USG guidance offers visualization of blood vessels and avoids necrotic component during sampling. This
avoids potential haemorrhagic complications and increases
the yield.
Technique Patient is placed in the supine position. For lat-
erally located lesions, an oblique decubitus position is used
with a cushion or bolster underneath the elevated side for
comfort. The lesion is visualized on USG and the tract for
needle passage is planned avoiding any vessels and necrotic
components. It is advisable to enter as close to the lesion for
favourable surgical excision margins. For deep-seated
lesions, alternative approaches such as skin entry from a distant point keeping the needle parallel to the chest wall or
entering vertically and then ipping the needle horizontally
to achieve a parallel course can be used to improve safety
and efcacy (Fig.42.1). A small skin incision provides regular edges for better wound healing after giving local anaesthesia at the needle entry site. Automatic biopsy needles are
more commonly used for breast biopsies and at least four
tissue cores should be sent for histopathological analysis. A
clip may be placed within the tumour based on the institutional practice. After the procedure, rm compression is provided over the needle entry point and the lesion for a few
minutes.
42.2.3 MG-Guided Biopsy [3, 4]
It is reserved for microcalcications, asymmetries, architectural distortions, and small masses detected only on MG with
no USG correlate. MG-guided biopsies require an add-on
unit called Stereotaxy [1, 5]. This can be performed with the
patient in a sitting or prone position, the latter requiring a
dedicated prone table that is space consuming. A prone table
avoids the direct visualization of the procedure and the needle by the patient, making it more comfortable for them.
However, an upright position too is well tolerated once the
patient is appropriately counselled about the procedure.
Technique After patient preparation, 0, +15, and −15
degree stereotactic paired view images are acquired. The xand y-axis coordinates are visible, whereas the z-axis (depth
estimation) is calculated by a software, from the parallax of
the stereotactic images. The needle is placed in the holder.
a b
Fig. 42.1 USG-guided vacuum-assisted excision biopsy in a 26-yearold lady for BI-RADS 3 lesion. (a) shows the needle probe (white star)
placed along the inferior aspect of the lesion in the longitudinal plane.
(b) shows axial section of the lesion with short axis of the needle seen
well positioned in situ. It was proven to be a broadenoma which could
be excised on outpatient basis without obvious scar, in a young female
42 Breast Interventions: Biopsy andLocalization Techniques
cde
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h
f
A
B
Fig. 42.2 Stereotactic biopsy in a 47-year-old lady with suspicious
microcalcication on mammogram. (A) shows a stereotactic vacuumassisted biopsy unit attached to the mammography equipment containing a sample needle probe and sample collecting chamber (B). The
microcalcications can be identied on stereo scout (C) image and
Following the instillation of 2% lignocaine, the needle is
inserted through the skin, up to the calculated depth and tissue cores are obtained. A specimen radiograph is important
to demonstrate the presence of calcication within these
cores (Fig.42.2). These can be marked or labelled to assist
the pathologist for assessment.
g
paired +15 and −15 degree views (D, E) followed by inserted biopsy
needle at the target site (F, G). The specimen radiograph conrms presence of calcication within (H). Histopathological assessment conrmed it to be an invasive breast carcinoma (ER+/ PR+/ Her2 neu+)
and there lies the need for CEM-guided biopsy. CEM biopsy
units are now available making such occult lesions amenable
to be targeted for obtaining tissue samples.
42.2.4 MRI-Guided Biopsy [1, 11–13]
Tomosynthesis-Guided Biopsy [4, 6, 7] A dedicated software upgrade is required for tomosynthesis-guided biopsies.
The advantage is its utility in targeting lesions that are appreciated in only one view of MG or are tomosynthesis detected
asymmetries, architectural distortion, radial scar or calcications. The technique overall remains similar to the stereotactic biopsy.
Contrast Enhanced Mammography (CEM)—Guided
Biopsy [8–10] The new technology of CEM has been gain-
ing popularity due to its ability to demonstrate perfusion
characteristics of the lesion. Occasionally, the lesions seen
on CEM have no correlation with other imaging modalities,
MRI-detected lesions are usually detected on a second-look
US, with proper anatomical localization after obtaining reference to clock position and depth. Occasionally, such
lesions cannot be identied on USG.Such masses and nonmass enhancement detected only on MR require MR-guided
biopsy.
Technique It is performed after performing the standard
dynamic contrast-enhanced MRI for the patient using dedicated breast coils, with the patient lying in the prone position. It needs special add-on MR-compatible hardware,
software and console. The lateral and medial pillars that
rmly immobilize the breast during diagnostic MRI are
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Fig. 42.3 MR-guided biopsy in a 41-year-old lady with left breast carcinoma in lower outer quadrant and an additional BI-RADS 3 lesion in
upper central region with no USG correlate. This additional lesion
appears isointense on T2W imaging (a) and shows early enhancement
on post-contrast subtracted sequence (b) (horizontal arrow). Planning
sequence for MRI-guided VABB shows the skin marker (vertical arrow)
replaced with fenestrated pillars, consisting of multiple
grids. The needle is introduced through a chosen grid window depending on the target location. The three-dimensional
axes are calculated either manually or digitally by a software. After lignocaine instillation, a needle is introduced and
sample is taken, preferably with a vacuum system for optimal results, followed by clip placement (Fig.42.3).
42.2.5 Vacuum-Assisted Biopsy [1, 4, 14, 15, 16]
Vacuum-assisted biopsy (VAB) enables one-time insertion
of a thick needle into the suspicious site and obtaining the
tissue core into a sample chamber using a vacuum apparatus.
This needs dedicated equipment and needle assembly which
varies from vendor to vendor. The technique of biopsy
remains the same with the only difference that instead of
in the axial section (c) and coronal section (d). During intervention,
correct position of the obturator is seen with its tip within the lesion (e).
Post-biopsy image (f) depicts post-biopsy changes with shortening due
to haemorrhagic products (circle). Histopathology conrmed it to be a
broadenoma, thus facilitating BCS for her
using a core needle, a VAB needle comprising a large side-on
aperture proximal to a sharp tip is used. The needle may be
placed just above or below the lesion, or through its centre,
and clock positions are customized based on the needlelesion relation. The site undergoes saline irrigation after
obtaining the tissue cores, and some authors prefer to use
intra-procedure lignocaine instillation to increase patient
comfort.
VAB has been shown to have similar efcacy as excision
biopsy with lower rates of repeat biopsy or rad-path discordance as compared to core needle biopsy. However, it needs
skill and expertise to operate, in addition to being costlier,
which limits its utility as a routine practice. Hence, VAB has
been reserved mostly for patients with rad-path discordance
and for stereotactic biopsies. It has gained wide popularity for
removal of broadenomas in young females because it can be
performed under local anaesthesia with no disguring scar.