Chris I. Flowers, MD, FACR, is an Associate Professor of
Oncological Science at the University of South Florida, Tampa, and the
Director of Breast Imaging and Research at the Moffitt Cancer Center and
Research Institute, WCB-RAD-MD, Tampa, FL.
Breast cancer is
one of the most common cancers in the United States, killing an
estimated 40,000 women annually, and was newly diagnosed in
approximately 190,000 women in 2009, according to NCI SEER data
(National Cancer Institute Surveillance Epidemiology and End Results).
diagnose these cancers, at least 5 times this number will require a
biopsy to determine whether a finding is benign or malignant. In the
U.S. alone, this equates to approximately 1 million breast biopsies per
Nonpalpable cancers are usually picked up at a screening
mammogram, and there has been a concomitant rise in the number of ductal
carcinoma in situ diagnosed as a side effect of screening, which has
caused some debate. Palpable findings, however, especially in younger
women, occur frequently, and are usually the subject of image-guided
biopsy to make the diagnosis.
As a result, biopsy is commonly used
by breast imaging radiologists and focused on lesions falling into
categories 4 (suspicious) and 5 (highly suspicious) of the BIRADS
reporting system.1 Once the preserve of breast
interventionalists, biopsy is now in the armamentarium of every
practicing radiologist interpreting mammograms, and is a routine part of
In performing breast biopsy, the challenges we face on a daily basis are as follows:
- Ensuring adequate anesthesia;
- Preventing bleeding;
- Obtaining representative
sampling of a lesion; and,
- Ensuring that we achieve
We will discuss each of these issues and offer some pointers and practical advice in this article.
patient told that she needs a biopsy suffers considerable anxiety, as
most patients fear that they will be given a cancer diagnosis. There are
even measurable systemic effects from the biopsy procedure.2
Therefore, to obtain a good quality biopsy, we need to ensure that the
patient is comfortable during the procedure, being adequately
anesthetized. This applies as much to stereotactic core biopsy as to
magnetic resonance imaging (MRI) guided biopsy, both of which may take a
prolonged time from start to finish.
Local anesthesia (LA)
procedures using simple Lidocaine 1%, or combined with 1:100,000
Epinephrine (EPI) are identical to those of other radiological
procedures.3-5 As LA is supplied as hydrochloride, and it
must be nonionized to enter the nerve endings, it may be buffered with
8.4% sodium bicarbonate (Table 1). The resulting reduction in acidity
also assists in reducing the ‘burn’ associated with the injection and
improved patient comfort.
Another proven method of reducing the
discomfort from the LA injection is to warm the Lidocaine to body
temperature before injection.6-12
vacuum-assisted biopsy (VAB), due to the dead space of the needle distal
to the sample notch, which may be up to 1 cm, at least 1.5 cm beyond
the area being biopsied, should be anesthetized. In practice, this means
using a long needle (eg, spinal needle) and intentionally injecting
beyond the lesion. If you are performing a stereotactic biopsy, you can
inject from the deepest part of the breast adjacent to the Bucky, all
the way out to the skin.
Reduction of residual pain from deep VAB may be mitigated by a second LA injection.2 If you are using LA with EPI, avoid intradermal injection (to lessen the risk of skin necrosis).13
Sub-dermal injection does not have the same danger. LA combined with
EPI has several advantages: It reduces bleeding by local
vasoconstriction, prolongs anesthesia to approximately 6 hours, and
reduces the systemic concentration, therefore making it rare for the
patient to get toxic effects.
The syringe of LA can also be used
for ‘blunt dissection’ – you can lift a mass off an implant/chest wall,
or the skin, by injecting as you advance the needle slowly. Once you
obtain a small, fluid-filled cavity, advance the needle while still
injecting. This technique is similar to the surgical technique of blunt
tissue dissection using forceps rather than a cutting blade.
Use a long needle (eg, spinal needle) and intentionally inject beyond
the lesion. If you are performing a stereotactic biopsy, you can inject
from the deepest part of the breast adjacent to the Bucky, all the way
out to the skin.
Difficult areas to anesthetize and the use of regional blocks
areas of the breast, in particular the immediate sub-areolar region,
are difficult to anesthetize fully. As a result, if the patient then has
a bad experience with her biopsy, she may never return for another
An alternative technique, known as a regional anesthesia, is a ‘Nipple Block.’14 Your breast surgeon may be willing to teach this to you.
of the most effective simple ways of achieving full anesthesia of the
nipple areola complex (NAC) is to use topical Lidocaine, either as
viscous Lidocaine or as a eutectic mixture of local anesthetics (EMLA,
APP Pharmaceuticals) cream. Using EMLA 30 min prior to the procedure for
a sub-areolar mass or a ductogram makes the process easier for yourself
and the patient.
If adequate anesthesia has not been obtained
there are two parts of the nipple block that can assist. The first is to
inject in a stepwise manner, around the nipple areola margin (Figure
The second can achieve complete anesthesia, such that some
surgeons can do a mastectomy. This requires the addition of a pool of 5
ml LA injected centrally in the breast, in the retro-glandular region.
This takes out the penetrating branches of the intercostal nerves. This
is easily achieved under ultrasound guidance from the lateral aspect of
the breast (Figure 2).
Practice point: Good anesthesia
is the key to a cooperative patient and a successful biopsy, but
consider topical LA gels and regional block if the lesion is sub-areolar
Prevention of bleeding: aspirin, warfarin, and clopidogrel
intervention in the breast may be complicated by hemorrhage/hematoma
formation during, or following, the procedure. This is more common with
the use of aspirin, warfarin (CoumadinTM) or clopidogrel (Plavix TM, Sanofi-Aventis, US).
first confirmation that breast biopsy was safe to perform in patients
on aspirin, heparin, or warfarin was published in 2000.15 This study was from an academic center, but it confirmed something that had been suspected for a long time.
The findings were validated in late 2008, when an article from community practice was published.16
This article showed that there was no significant risk of bleeding when
patients are on aspirin or warfarin, and patients only need to be
consented for an increased risk of hemorrhage/hematoma. A patient with a
‘therapeutic range’ INR, within 2 weeks of the procedure, is safe to
biopsy. The only patients we still do not like to biopsy without
withdrawal of therapy are those being treated with clopidogrel.
Breast biopsy is safe in patients on antiplatelet or anticoagulant
therapy, yet doubts still remain about patients on clopidogrel.
Representative sampling: Targeting and sampling error
One of the goals of a successful biopsy is to achieve adequate tissue
sampling. This means that enough tissue is excised for pathological
diagnosis. This is referred to as ‘representative’ sampling.
The choice of modality for biopsy and the size of the needle are important in obtaining a satisfactory tissue sample.
ultrasound masses, it is often best to get a margin of a mass as part
of the procedure, especially in the case of stromal sclerosis,
fibrocystic change presenting as a mass, or hamartomas, as the central
part of the mass may look like normal benign tissue under the
microscope, whereas if a margin is included (Figure 3), then the
pathologist may be able to identify a ‘mass,’ and report it as such.
calcifications are usually sampled by stereotaxis and a specimen x-ray
is obtained to determine whether enough calcification was sampled to be
representative of a lesion. If the calcified area is visible and
biopsied under ultrasound guidance (Figure 4), then a specimen x-ray
should be performed as if it had been performed under stereotaxis, to
document removal of calcifications and representative sampling.
size makes a difference when it comes to the issue of under-estimation
of DCIS or invasive cancer. This is caused by not truly getting tissue
that is a representative sample. Commonly, this occurs in a patient with
suspicious calcifications and a core biopsy of atypical ductal
hyperplasia (ADH), which eventually turns out to be DCIS.
important is the underestimation of invasive disease, when only DCIS is
found at core biopsy. We can reduce this variant of sampling error by
targeting the asymmetric density/mass associated with suspicious
calcifications (where there is an increased chance of finding invasive
cancer at core).17, 18
Invasive disease is an important
diagnosis to make pre-operatively, as the diagnosis of invasion
mandates sentinel lymph node biopsy (SLNB), which otherwise is not
required for ‘noninvasive’ disease.
Tables 2 and 3 demonstrate the
differences between needle size and estimates of underestimation of ADH
and ductal carcinoma in situ (DCIS) by publication.
The larger the needle, the less under-estimation and, therefore,
sampling error. It is important to note that a diagnosis of ADH
currently requires surgical excision.38 Similar rates are found in patients having ultrasound or MRI-guided core biopsy.39-49
and unusual histological findings are as follows: The diagnosis of
papilloma, and the role of subsequent surgical excision remain
controversial. There is an even split in papers between excision and
routine follow-up for women with a lesion compatible with a papilloma on
imaging, with a pathology diagnosis of papilloma.50-61 However, the diagnosis of atypia or a papillary lesion always requires surgical excision.38
are several other reasons for making a surgical excision following a
core biopsy result. This may be to minimize false negative core biopsy
or because of the need to excise surgically despite nonmalignant
diagnosis at core biopsy. Additional reasons are as follows:
- Pathologist recommendation,
- Radiologic pathologic
- Histological underestimation, and,
- Unusual or ‘borderline’
Some patients request that a palpable but proven benign lesion be
surgically removed. This is one of the developing indications for the
diagnostic excision of these lesions, either following a benign fine
needle aspiration (FNA) or a core result.62-65 This is easily
accomplished for lesions under 2 cm, with the reduction in costs
associated with a fast outpatient procedure, and lesser morbidity (there
is less visible scarring; therefore, it is useful in younger adults).
Even if the fibroadenoma cannot be completely removed, the lesion has
been debulked and is usually no longer palpable, and the patient can
feel on the breast that the lump is gone, improving psychological
Recurrence is possible if the lesion is more than 3 cm in size, but the procedure can be repeated without harm to the patient.65
The only exception (by size definition) is the juvenile fibroadenoma,
which has a propensity to local recurrence, even with surgical excision.
when performing a biopsy for calcifications, it is important to
consider whether we have obtained a representative specimen.
the specimen x-ray and compare it with the diagnostic images. We need
to ensure that not only has calcium been harvested, but also whether the
calcium harvested is representative of the lesion. Calcium then seen
on histology can be correlated with that seen on the mammogram.
A practice tip is to compare the specimen x-ray with the original
prebiopsy diagnostic mammogram and determine whether you have calcium
that represents what you see on the spot magnification films.
Concordance: Rad–path correlation
the physician responsible for the biopsy, you are required to determine
whether the pathological diagnosis reported to you fits the
radiological findings. Another way of looking at it is to ask the
question: Do the pathology results make sense in light of the clinical
and imaging findings? If yes, there is concordance; if no, there is
discordance. If there is doubt, it is always worth discussing with the
pathologist, and even comparing what is seen under the microscope with
the mammographic findings. One of the best ways to do this is to have a
regular radiological-pathological meeting (Rad-Path) to discuss cases
that are not straightforward. It is a good learning process for both
How do you
deal with a case of representative calcification sampling, seen on
specimen x-ray, but a finding of ‘no calcifications seen’ on the
Ask to x-ray the specimen blocks if there are
relatively few calcifications, or if the initial report is negative.
This is best done in 2 planes—AP and lateral (Figure 5). A relatively
high dose is required, using manual exposure, to get the best possible
image quality. Once calcifications are identified, the blocks can then
be returned to pathology with the specimen block x-rays, with details of
which block contains the calcifications, and at what depth the
calcifications are located in the block.
In Figure 5, the
calcification is present but lies very superficially in one block. The
pathologist must be informed that the calcification lies in the first
1/3 of the block, with one calcification particle at the anterior edge.
is an important finding, as when the technician is making the slides
from the blocks, the microtome shavings of the first few slices are
discarded until a contiguous piece of tissue can be cut, and floated
onto the slide. In this way, microcalcifications can be lost.66 Other reasons for calcifications going missing are:
- Microtome ‘knocked out’
calcifications (‘skid marks’
on slide), and
- Calcium oxalate crystals—best viewed under polarized light.67, 68
Practice point: If you have trouble with missing
calcifications in pathology, x-ray the pathology blocks and check with
polarized light for calcium oxalate.
performing a breast biopsy, whether it be ultrasound, stereotactic or
MRI-guided core biopsy, radiologists face challenges with ensuring
adequate anesthesia, reduction of bleeding, representative sampling, and
rad/path concordance. Practice points are provided to assist
radiologists in applying the appropriate techniques, upon making a
significant finding in biopsied lesions.
- American College of Radiology breast imaging reporting and data system atlas (BI-RADS Atlas). Reston, VA: American College of Radiology (ACR); 2003.
EV, Berbaum KS, Lutgendorf SK. Large-core breast biopsy: Abnormal
salivary cortisol profiles associated with uncertainty of diagnosis. Radiology. 2009;250:631-637.
- Reynolds HE, Jackson VP, Musick BS. Preoperative needle localization in the breast: utility of local anesthesia. Radiology. 1993;187:503-505.
PJ, Sergentanis TN, Zagouri F, Zografos GC. Health-related quality of
life in vacuum-assisted breast biopsy: Short-term effects, long-term
effects and predictors. Health and Quality of Life Outcomes. 2010;8:11.
- Novy DM, Price M, Hunyh PT, Schuetz A. Percutaneous core biopsy of the breast: Correlates of anxiety. Academic Radiology. 2001;8:467-472.
- Martin S, Jones JS, Wynn BN: Does warming local anesthetic reduce the pain of subcutaneous injection? Am J Emerg Med. 1996;14:10-12.
- Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med. 1998;16:353-356.
- Cragg AH, Berbaum K, Smith TP. A prospective blinded trial of warm and cold lidocaine for intra-dermal injection. AJR Am J Roentgenol. 1988;150:1183-1184.
- Klein EJ, Shugerman RP, Leigh-Taylor K, et al. Buffered lidocaine: Analgesia for intravenous line placement in children. Pediatrics. 1995;95:709-712.
- Luhmann J, Hurt S, Shootman M, Kennedy R. A comparison of buffered
lidocaine versus ELA-max before peripheral intravenous catheter
insertions in children. Pediatrics. 2004; 113;3:217-220.
- Matsumoto AH, Reifsnyder AC, Hartwell GD, et al. Reducing the discomfort of lidocaine administration through pH buffering. J Vasc Interv Radiol. 1994; 5:171-175.
Zagouri F, Sergentanis T, Gounaris A, et al. Pain in different methods
of breast biopsy: Emphasis on vacuum-assisted breast biopsy. The Breast. 2008;17:71-75.
Stoebner PE, Teot L, Colonna G, et al. Skin necrosis after ambulatory
phlebectomy: Reconstructive surgery using an artificial dermis. Dermatologic Surgery. 2006;32:972-975.
Kass R, Lind DS, Souba WW. ACS Surgery Section 3, Chapter 5 breast
procedures. www.acssurgery.com/acs/chapters/ch0305.htm. Accessed January
- Melotti MK, Berg WA. Core needle breast biopsy in patients undergoing anticoagulation therapy. AJR Am J Roentgenol. 2000;174:245-249.
- Somerville P, Seifert PJ, Destounis SV, et al. Anticoagulation and bleeding risk after core biopsy. AJR Am J Roentgenol. 2008;191:1194-1197.
- Bagnall MJC, Evans AJ, Wilson ARM, et al. Predicting invasion in mammographically detected microcalcification. Clinical Radiology. 2001;56:828-832.
Huo L, Sniege N, Hunt KK, et al. Predictors of invasion in patients
with core-needle biopsy-diagnosed ductal carcinoma in situ and
for a selective approach to sentinel lymph node biopsy in ductal
carcinoma in situ. Cancer. 2006;107:1760-1768.
L, Smolkin JH, Dershaw D, et al. Calcification retrieval at
stereotactic, 11- gauge, directional, vacuum-assisted breast biopsy. Radiology. 1998;208:251-260.
Philpotts LE, Shaheen NA, Carter D, et al. Comparison of rebiopsy rates
after stereotactic core needle biopsy of the breast with 11-gauge
vacuum suction probe versus 14-gauge needle and automatic gun. AJR Am J Roentgenol. 1999;172:683-687.
Darling ML, Smith DN, Lester SC, et al. Atypical ductal hyperplasia and
ductal carcinoma in situ as revealed by large-core needle breast
biopsy: Results of surgical excision. AJR Am J Roentgenol. 2000;75:1341-1346.
- . Philpotts LE, Lee CH, Horvath LJ, et al. Underestimation of breast cancer with 11-gauge vacuum suction biopsy. AJR Am J Roentgenol. 2000;175:1047-1050.
Berg WA, Arnoldus CL, Teferra E, Bhargavan M. Biopsy of amorphous
breast calcifications: Pathologic outcome and yield at stereotactic
biopsy. Radiology. 2001;221:495-503.
- Jackman RJ, Burbank
F, Parker S, et al. Stereotactic breast biopsy of nonpalpable lesions:
Determinants of ductal carcinoma in situ underestimation rates. Radiology. 2001;218:497-502.
- Hoorntje LE, Peeters PH, Mali WP, Borel Rinkes IHM. Vacuum-assisted breast biopsy: A critical review. Eur J Cancer. 2003;39:1676-1683.
Philpotts LE, Hooley RJ, Lee CH. Comparison of automated versus
vacuum-assisted biopsy methods for sonographically guided core biopsy of
the breast. AJR Am J Roentgenol. 2003;180:347-351.
Lomoshitz FM, Heibich TH, Rudas M, et al. Stereotactic 11-gauge
vacuum-assisted breast biopsy: Influence of number of specimens on
diagnostic accuracy. Radiology. 2004;232:897-903.
Lourenco AP, Mainiero MB, Lazarus E, et al. Stereotactic breast biopsy:
Comparison of histologic underestimation rates with 11- and 9-gauge
vacuum-assisted breast biopsy. AJR Am J Roentgenol. 2007;189:275-279.
Liberman L, Holland AE, Marjan D, Murray MP, et al. Underestimation of
atypical ductal hyperplasia at MRI-guided 9-gauge vacuum-assisted
breast. AJR Am J Roentgenol. 2007;188:684-690.
Sigalzafrani B, Muller K, Elkhoury C, et al. Vacuum-assisted large-core
needle biopsy (VLNB) improves the management of patients with breast
microcalcifications—Analysis of 1009 cases. European Journal of Surgical Oncology. 2008;34:377-381.
Schueller G, Jaromi S, Ponhold L, et al. US-guided 14-gauge core-needle
breast biopsy: Results of a validation study in 1352 cases. Radiology. 2008;248:406-413.
Hoang J, Hill P, Cawson J. Can mammographic findings help discriminate
between atypical ductal hyperplasia and ductal carcinoma in situ after
needle core biopsy? The Breast. 2008;17:282-288.
JH, Kim EK, Kim MJ. Atypical ductal hyperplasia diagnosed at
sonographically guided 14-gauge core needle biopsy of breast mass. AJR Am J Roentgenol. 2009;192:135-141.
Eby PR, Ochsner JE, Demartini WB. Frequency and upgrade rates of
atypical ductal hyperplasia diagnosed at stereotactic vacuum-assisted
breast biopsy: 9-versus 11-gauge. AJR Am J Roentgenol. 2009;192:229-233.
Won B, Reynolds HE, Lazaridis CL, Jackson VP. Stereotactic biopsy of
ductal carcinoma in situ of the breast using an 11-gauge vacuum assisted
device: Persistent underestimation of disease. AJR Am J Roentgenol. 1999;173:227–229.
Lee CH, Carter D, Philpotts LE, et al. Ductal carcinoma in situ
diagnosed with stereotactic core needle biopsy: Can invasion be
predicted? Radiology. 2000;217:466-470.
- Brem RF,
Schoonjans JM, Goodmas SN, et al. Nonpalpable breast cancer:
Percutaneous diagnosis with 11- and 8-gauge stereotactic vacuum-assisted
biopsy devices. Radiology. 2001;219:793-796.
RJ, Birdwell RL, Ikeda DM. Atypical ductal hyperplasia: Can some lesions
be defined as probably benign after stereotactic 11-gauge
vacuum-assisted biopsy, eliminating the recommendation for surgical
excision? Radiology. 2002;224:548-554.
- Cardenosa G. Needle choice for sonographically guided core biopsy. AJR Am J Roentgenol. 1999;173:845- 846.
Mainiero MB, Koelliker SL, Lazarus E, et al. Ultrasound-guided
large-core needle biopsy of the breast: Frequency and results of repeat
biopsy. J Women Imaging. 2002;4:52-57.
- Sauer G, Deissler
H, Strunz K, et al. Ultrasound-guided large-core needle biopsies of
breast lesions: Analysis of 962 cases to determine the number of samples
for reliable tumour classification. Br J Cancer. 2005;92:231-235.
- Fishman JE, Milikowski C, Ramsinghani R, et al. US-guided core-needle biopsy of the breast: How many specimens are necessary? Radiology. 2003;226:779-782.
- Lee J, Kaplan JB, Murray MP, et al. Underestimation of DCIS at MRI-guided vacuum-assisted breast biopsy. AJR Am J Roentgenol. 2007;189:468-474.
Jang M, Cho N, Moon WK, et al. Underestimation of atypical ductal
hyperplasia at sonographically guided core biopsy of the breast. AJR Am J Roentgenol. 2008;191:1347-1351.
Zagouri F, Sergentanis T, Koulocheri D, et al. Atypical ductal
hyperplasia: A way to minimize underestimation in vacuum-assisted breast
biopsy? The Breast. 2008;17;1-6.
- Renshaw, AA,
Cartagena, M, Schenkman, RH, et al. Atypical ductal hyperplasia in
breast core needle biopsies. Correlation of size of the lesion, complete
removal of the lesion, and the incidence of carcinoma in follow-up
biopsies. Am J Clin Pathol. 2001;116:92.
- Sneige, N, Lim,
SC, Whitman, GJ, et al. Atypical ductal hyperplasia diagnosis by
directional vacuum-assisted stereotactic biopsy of breast
microcalcifications. Considerations for surgical excision. Am J Clin Pathol. 2003;119:248.
Killebrew LK, Oneson RH. Comparison of the diagnostic accuracy of a
vacuum-assisted percutaneous intact specimen sampling device to a
vacuum-assisted core needle sampling device for breast biopsy: initial
experience. The Breast Journal. 2006;12:302-308.
Sigalzafrani B, Muller K, Elkhoury C, et al. Vacuum-assisted large-core
needle biopsy (VLNB) improves the management of patients with breast
microcalcifications – Analysis of 1009 cases. Eur J Surg Oncol. 2008;34:377-381.
- Page DL, Salhany KE, Jensen RA, Dupont WD. Subsequent breast carcinoma risk after biopsy with atypia in a breast papilloma. Cancer. 1996;78;258-266.
Lewis JT, Hartmann LC, Vierkant RA et al. An analysis of breast cancer
risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol. 2006;30:665-672.
- Kraus FT, Neubecker RD. The differential diagnosis of papillary tumors of the breast. Cancer. 1962;15:444-455.
Papotti M, Eusebi V, Gugliotta P, Bussolati G. Immunohistochemical
analysis of benign and malignant papillary lesions of the breast. Am J Surg Pathol. 1983;7:451-461.
Rabban JT, Koerner FC, Lerwill MF. Solid papillary ductal carcinoma in
situ versus usual ductal hyperplasia in the breast: A potentially
difficult distinction resolved by cytokeratin 5/6. Hum. Pathol. 2006;37:787-793.
- Liberman L, Bracero N, Vuolo MA, et al. Percutaneous large-core biopsy of papillary breast lesions. AJR Am. J. Roentgenol. 1999;172:331-337.
Philpotts LE, Shaheen NA, Jain KS, et al. Uncommon high-risk lesions of
the breast diagnosed at stereotactic core needle biopsy: Clinical
importance. Radiology. 2000;216:831-837.
- Mercado CL,
Hamele-Bena D, Singer C et al. Papillary lesions of the breast:
evaluation with stereotactic directional vacuum- assisted biopsy. Radiology. 2001; 221:650-655.
- Mercado CL, Hamele-Bena D, Oken SM, et al. Papillary lesions of the breast at percutaneous core-needle biopsy. Radiology. 2006;238:801–808.
Sydnor MK, Wilson JD, Hijaz TA, et al. Underestimation of the presence
of breast carcinoma in papillary lesions initially diagnosed at
core-needle biopsy. Radiology. 2007;242:58-62.
- Shah VI,
Flowers CI, Douglas-Jones AG, et al. Immunohistochemistry increases the
accuracy of diagnosis of benign papillary lesions in breast core needle
biopsy specimens. Histopathology. 2006;48:683-691.
Liberman L, Tornos C, Huzjan R, et al. Is surgical excision warranted
after benign, concordant diagnosis of papilloma at percutaneous breast
biopsy? AJR Am J Roentgenol. 2006;186:1328-1334.
RE, Boyd BA, Whitworth PW, et al. Percutaneous removal of benign breast
masses using a vacuum-assisted hand-held device with ultrasound
guidance. Am J Surg. 2002;184:332.
- Tagaya N, Nagagawa A,
Ishikawa Y, et al. Experience with ultrasonographically guided vacuum
assisted resection of benign breast tumors. Clinical Radiology. 2008;63:396-400.
- Johnson A, Henry-Tillman R, Smith L, et al. Percutaneous excisional biopsy. Am J Surg. 2002;184:550–554.
Grady I, Gorsuch H, Wilburn-Baily S. Long-Term Outcome of Benign
Fibroadenomas Treated by Ultrasound-Guided Percutaneous Excision. The Breast Journal. 2008;14:275-278.
Winston JS, Geradis J, Liu DF, Stomper PC. Microtome shaving
radiography: Demonstration of loss of mammographic microcalcifications
histologic sectioning. The Breast Journal. 2004;10: 200-203.
- Tornos C, Silva A, El-Naggar A, Pritzker KP. Calcium oxalate crystals in breast biopsies: The missing calcifications. Am J Surg Pathology. 1990;14:961-968.
D’Orsi C, Reale FR, Davis MA, Brown VJ. Is calcium oxalate an adequate
explanation for non-visualization of breast specimen calcification. Radiology. 1992;182:801-803.