Pseudoaneurysm of the breast: case study and review of literature

This paper describes the B-mode, colour and spectral Doppler appearances of breast pseudoaneurysm - a rare vascular complication of ultrasound-guided needle core biopsy. Previously reported cases of spontaneous and iatrogenic pseudoaneurysm of the breast are reviewed. The significance of this potentially serious complication is discussed with reference to the increasing use of imaging and image guided techniques in the diagnosis of breast disease.     

Pseudoaneurysm after an ultrasound-guided breast core needle biopsy in a lactating woman

This is a case report of a lactating woman in her twenties diagnosed with a breast pseudoaneurysm following a 14-gauge ultrasound-guided core needle biopsy detected by a Color Doppler exam, and treated with surgery. Further discussion concerning the patient’s symptoms, useful imaging modalities, and treatment options are included. Knowledge on this complication is crucial for the correct diagnosis and best management and treatment.     

Acute Coronary Artery Air Embolism Following CT-Guided Lung Biopsy

CT-guided needle biopsy is a common procedure for obtaining a tissue diagnosis and consequently correctly managing patients. This procedure has many potential complications, ranging from simple pneumothorax or self-limiting hemoptysis to life-threatening pulmonary hemorrhage and air embolism. Though the latter is a rare complication of CT-guided needle biopsy, it has attracted a lot of interest. We report a case of right coronary air embolism resulting in myocardial infarction after a CT-guided percutaneous needle biopsy of the lung.     

Seeding of tumour cells following breast biopsy: a literature review

Needle biopsy of the breast is widely practised. Image guidance ensures a high degree of accuracy. However, sporadic cases of disease recurrence suggest that in some cases the procedure itself may contribute to this complication. This article reviews evidence relating to needle biopsy of the breast and the potential for tumour cell migration into adjacent tissues following the procedure. A literature search was undertaken using Medline, Embase and the Cochrane Library. Results are grouped under three categories: histological evidence of spread, clinical evidence of recurrent disease and the likelihood of seeding dependent upon tumour type. There is histological evidence of seeding of tumour cells from the primary neoplastic site into adjacent breast tissue following biopsy. However, as the interval between biopsy and surgery lengthens then the incidence of seeding declines, which suggests that displaced tumour cells are not viable. Clinical recurrence at the site of a needle biopsy is uncommon and the relationship between biopsy and later recurrence is difficult to confirm. There is some evidence to suggest that cell seeding may be reduced when vacuum biopsy devices are deployed.     

Four Cases of a Cerebral Air Embolism Complicating a Percutaneous Transthoracic Needle Biopsy

A percutaneous transthoracic needle biopsy is a common procedure in the practice of pulmonology. An air embolism is a rare but potentially fatal complication of a percutaneous transthoracic needle biopsy. We report four cases of a cerebral air embolism that developed after a percutaneous transthoracic needle biopsy. Early diagnosis and the rapid application of hyperbaric oxygen therapy is the mainstay of therapy for an embolism. Prevention is the best course and it is essential that possible risk factors be avoided.     

Coronary artery air embolism: a potentially fatal complication of CT-guided percutaneous lung biopsy

CT-guided transthoracic lung biopsy is becoming a widely accepted procedure for the diagnosis of pulmonary lesions. The rate of severe complications following such a procedure has been reported. Of these complications, air embolism is the most likely to be fatal. We report a case of right coronary air embolism resulting in myocardial infarction after a CT-guided percutaneous needle biopsy of the lung. The patient died from underlying malignant disease 4 months later.Coronary artery air embolism, a condition with a high mortality rate, mostly results from the iatrogenic introduction of gas bubbles into the bloodstream. Direct injection of air or gas into major arterial vessels during cardiac catheterisation or interventional radiological angiography has been reported; however, it also is a rare complication of CT-guided percutaneous transthoracic biopsy of the lung. In the literature, 19 possible causes for air embolism are listed [1]. Of these, two are generally accepted as the most probable causes: communication of the ambient air with a pulmonary vein via the biopsy needle, or development of a bronchial-venous fistula at the needle tract or site of the core sample. We report a case of air embolism in the aorta and right coronary artery resulting in myocardial infarction after a CT-guided percutaneous needle biopsy of lung.     

Fatal air embolism as a complication of CT-guided needle biopsy of the lung

A CT-guided needle lung biopsy carries a risk of potential air embolization. We present a rare case of air embolization after this procedure. Postmortem CT revealed air in the cerebral arteries and the left ventricle. This complication is extremely rare; however, it becomes fatal when it happens. Several points to prevent this fatal complication are discussed.     

Percutaneous Repair of Radial Artery Pseudoaneurysm in a Hemodialysis Patient Using Sonographically Guided Thrombin Injection

We report a case of a radial artery pseudoaneurysm complicating an incorrect puncture of a Brescia-Cimino hemodialysis fistula that was treated with percutaneous ultrasound-guided thrombin injection. The pseudoaneurysm recurred after the initial successful thrombin injection. With a second injection we obtained permanent pseudoaneurysm occlusion. Our case illustrates that this procedure is an effective treatment in this type of arteriovenous fistula complication. We compare this case with the only similar one we could find in the literature.     

Air Embolism Detected During Computed Tomography Fluoroscopically Guided Transthoracic Needle Biopsy

Air embolism is a rare but potentially fatal complication of percutaneous needle biopsy of the lung. We report a case of cerebral air embolism which occurred during computed tomography (CT)-guided needle biopsy. Air entering the aorta is depicted on CT-fluoroscopy images of the procedure.     

Ultraschallgezielte Stanzbiopsie der Mamma: Technik,Ergebnisse, Indikationen

Purpose. The purpose of this retrospective analysis was to assess the diagnostic accuracy and complication rate of sonographically guided core needle biopsy in palpable breast masses, mammographically detected nonpalpable lesions, and sonographically detected clinically and mammographically occult lesions. Patients and methods. Sonographically guided core needle biopsy was performed in 590 lesions in 572 patients, by using an automated biopsy gun with a 14-gauge large core needle and a coaxial system. Core needle biopsy results were compared with surgical biopsy in 265 cases. 325 lesions with benign histologic diagnoses were followed up for at least 18 months. Results. 234 carcinomas and 356 benign abnormalities were found in the 572 patients. Core needle biopsy reached a sensitivity of 98.7% at a specificity of 99.7%. Understimation rates for lesions initially diagnosed as DCIS and for lesions initially diagnosed as ADH were 3/10 and 6/14, respectively. Of three false-negative results, two were immediately recognized, and one was identfied at follow-up. Serious bleeding occured in one patient (0.2% complication rate). Conclusions. This report confirms that sonographically guided large core needle biopsy is a safe, reliable and cost-effective method for the assessment of both palpable and nonpalpable, mammographically and sonographically detected breast abnormalities.     

CT-guided core needle biopsy of breast lesions visible only on MRI

OBJECTIVE: As breast MRI has become more widely used, the need to biopsy suspicious lesions visible only on MRI has increased. A small percentage of these lesions are not amenable to MR-guided biopsy. We report our technique of CT-guided core needle biopsy of breast lesions. CONCLUSION: CT-guided core needle biopsy is a safe and effective method for sampling breast lesions visible only on MRI when MR-guided biopsy is not feasible.     

Seeding of malignant cells into the needle track after lung and pleural biopsy

Transthoracic needle biopsy is frequently performed for the diagnosis of pulmonary and pleural disease. Seeding of malignant cells is a potential complication but is extremely uncommon. We report the second patient with malignant seeding after fine-needle aspiration biopsy of a bronchogenic carcinoma. We also report a patient with seeding of bronchogenic carcinoma after a pleural biopsy. Because seeding is a rare complication, it does not affect the indications for biopsy.     

Rapid 3D reconstruction guided embolization for catastrophic bleeding following vacuum assisted breast biopsy; A case report and review of the literature

The most clinically significant complication associated with stereotactic core needle biopsy of the breast is hematoma formation, which only occurs in less than 1% of biopsies and may require treatment. Cases of uncontrollable bleeding, refractory to repeated compression, resulting from biopsy are exceedingly rare. We present a case of catastrophic, uncontrollable bleeding and large hematoma formation resulting from stereotactic vacuum-assisted breast biopsy of a breast mass identified in screening mammography. Percutaneous embolization was planned and guided using 3D reconstructions from computed tomographic angiography, and bleeding was successfully controlled with micro-coil embolization.     

Percutaneous lung aspiration biopsy: a comparison between two fine needles.

Fine needle lung aspiration biopsy is now a well established method of obtaining tissue for histopathological diagnosis. It is fast, simple and reliable, and has a very low complication rate. We report our experience using two fine needles, the Turner and the EZ-EM Cut-Biopsy needles, comparing their yield and complication rates. We found that both needles had comparable diagnostic yields (65% with the Turner, and 71% with the EZ-EM) and complication rates. We also found that in most cases, aspirates alone were sufficient for diagnosis, and that obtaining tissue cores with larger bore EZ-EM needles did not significantly influence the diagnostic outcome. We conclude that both the Turner and the EZ-EM needles are equally effective and safe in percutaneous lung aspiration biopsy. The least traumatic needle should be used except when the cytological diagnosis is nonspecific inflammatory cells or inadequate, in which case a repeat with a cutting needle is advised to obtain a core of tissue.     

Freehand Two-Step CT-Guided Brain Tumor Biopsy: A Fast and Effective Interventional Procedure in Selected Patients

Purpose To evaluate the efficacy and safety of CT-guided needle biopsy of brain lesions without a stereotactic device, and to determine the best possible indications for this technique. Methods From February 2001 to February 2004, 20 patients (12 men, 8 women; age 61–82 years) underwent CT-guided brain lesion biopsy. The procedure started with a brain CT scan for lesion localization and for selection of the inlet for needle insertion. The patient was then transported to the operating room where cranioanatrisis was performed. Subsequently, the biopsy was performed under CT guidance using a 14G brain biopsy needle with a blind smooth end and lateral holes. At the end of the biopsy, the field was checked for possible complications with a CT scan. Results Histopathologic results were: brain tumor in 16 patients (80%), inflammatory process in 3 (15%), and no conclusive diagnosis in 1 (5%). A repeat of the process was required in 2 patients. A minor complication of local hematoma was found in 1 patient (5%). There were no deaths or other serious complications. Conclusion CT-guided biopsy is a reliable method for histopathologic diagnosis of brain lesions in selected cases. It is a simple, fast, effective, low-cost procedure with minimal complications, indicated especially for superficial and large tumors.     

Interventional MRI of the breast: lesion localisation and biopsy

With the growing use of breast MRI an increasing need exists for reliable MR-guided preoperative localisation or even MR-guided needle biopsy. In this article an overview is given of the different approaches and the present state of the art. With closed magnets the following approaches have been made: freehand localisation (similar to CT-guided freehand localisation), and freehand localisation combined with a frameless stereotaxic system operating with support by ultrasound. One localisation device for supine localisation and a thermoplastic mesh for breast stabilisation have been reported. Most investigators have used compression devices to immobilise the breast and prevent shift during needle insertion. Thus far, one immobilisation and aiming device has been designed for open magnets. A small number of experiences exist with interventions on open MR units using a navigation system. Wire localisations are presently a well-established procedure. Magnetic-resonance-guided needle biopsy has been accomplished in closed systems as well as by the use of breast immobilisation devices. However, problems still exist due to severe needle artefacts, tissue shift during the intervention and fast equalisation of contrast enhancement in lesions with surrounding tissue. Therefore, needle biopsy is not recommended for lesions < 10 mm. Magnetic-resonance-guided vacuum biopsy is somewhat more invasive but promises to solve most of these problems.     

Interventional breast procedures

The capability to provide histologic diagnoses of nonpalpable lesions by performance of percutaneous needle biopsy has revolutionized breast imaging in the past decade. The radiologist who performs percutaneous breast biopsies assumes an increased level of responsibility for the patient regarding patient selection, lesion selection, performance of the biopsy procedure, interpretation of results, and patient follow-up. With variable and increasingly numerous options for the biopsy of breast lesions, careful attention must be paid to the selection of patients and types of lesions for different procedures. Critical technical considerations affect whether biopsy of a lesion can be optimally performed percutaneously, and these considerations must be factored into the recommendations for patient treatment. In addition, a limited preprocedural clinical assessment of the patient will allow a safer procedure to be performed expeditiously. Most breast abnormalities classified by using the ACR Lexicon as 4 (suggestive) or 5 (highly suggestive, likely malignant) are suitable for either percutaneous breast needle biopsy or needle localization and excisional biopsy. In general, those lesions classified as 3 (probably benign) carry a recommendation for early follow-up and not biopsy, because the likelihood of malignancy is small. A particular advantage of percutaneous biopsy is in the diagnosis of multicentric breast cancer. Core biopsy is less invasive and less costly than surgical biopsy, and it can be used to demonstrate multicentric disease, saving the patient a two-step surgery. However, several lesions are better treated by excision than by percutaneous biopsy. Among these are architectural distortion or loosely arranged, segmental or regional microcalcifications. For nonpalpable breast lesions visualized on mammography, sonography, or both, imaging-guided localization is required for precise needle placement either for wire localization or for percutaneous breast biopsy. The selection of which modality to use for guidance depends on (1) the adequacy of visualization of the lesion by the modality used, (2) the position of the lesion, (3) the ease of positioning the patient, (4) the skill of the operator, (5) the need to reduce radiation exposure, (6) the overall patient condition, and (7) size of the lesion. Fine-needle aspiration biopsy (FNAB) has a high sensitivity and specificity in the diagnosis of palpable breast lesions when the procedure is properly performed and interpreted. Variable results have been achieved with FNAB of nonpalpable breast lesions under imaging guidance. Three critical components are necessary to achieve reliable results by using FNAB. These include the following: (1) accuracy in needle placement, (2) skill in performance of FNAB, and (3) expert cytopathologic analysis. Accurate preoperative needle localization of nonpalpable breast lesions allows the radiologist to guide the surgeon performing an open biopsy and helps to ensure that the surgical procedure can be performed quickly and can be accomplished with the best possible cosmetic result for the patient. Lesions selected for needle localization and biopsy should undergo a complete tailored imaging evaluation before the needle localization is scheduled. Specimen radiography should be performed for all nonpalpable lesions. Once the lesion has been identified on specimen radiography, the radiologist can assist the pathologist in identifying the lesion microscopically by marking the lesion within the surgical specimen. We cover the technical and interpretative aspects of percutaneous breast biopsy and needle localization for surgical biopsy.     

Transarterial Embolization of an Inferior Genicular Artery Pseudoaneurysm with Arteriovenous Fistula after Arthroscopy

Arthroscopic meniscectomy of the knee is generally a safe and effective procedure with a low rate of vascular complications. We report here on a unique case of a 55-year-old man with a lateral inferior genicular artery pseudoaneurysm and a concomitant arteriovenous fistula that developed after arthroscopic meniscectomy; this was successfully treated with selective angiographic embolization. This case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after an arthroscopic procedure.     

Ultrasound-guided core needle biopsy as an initial diagnostic test for palpable breast masses.

PURPOSE: To determine the role of ultrasound (US)-guided core needle biopsy as an initial diagnostic test for palpable breast masses. MATERIALS AND METHODS: Ninety-eight consecutive patients, each with a palpable breast mass, were referred for US-guided core biopsy by a multidisciplinary team of physicians who specialize in the care of breast diseases. All palpable breast masses were clearly visible on high-resolution US. Ninety-nine core needle biopsies were performed under local anesthesia with use of freehand technique, mostly in an outpatient setting. Core needle path through each mass was documented in two orthogonal sections. A mean of 3.4 tissue core samples (range, 1-7) were obtained in each patient. RESULTS: Core needle biopsy resulted in the diagnosis of 66 malignancies, two cases of atypical ductal hyperplasia (ADH), and 30 benign diseases of the breast. Surgery with curative intent was performed in 63 breast malignancies and excisional biopsies were performed for 10 benign diseases (two cases of ADH and eight benign lesions). Twenty-five breast masses were managed nonoperatively: chemotherapy was performed in three locally advanced breast cancers and 3-year follow-up was conducted for 22 benign lesions. Malignancies were correctly diagnosed in all cases. No malignancy was discovered at surgery or during clinical follow-up of ADH and no benign breast lesions were diagnosed by core needle biopsy. US-guided core needle biopsy is 100% sensitive and specific for palpable breast malignancies, with no false-positive results. A puncture site ecchymosis was the only morbidity or complication noted. CONCLUSION: US-guided core needle biopsy is a safe and accurate first diagnostic test for palpable breast masses that require tissue proof.     

Systemic air embolism after CT-guided transthoracic biopsy using a cutting needle

The authors report a case of systemic air embolism after CT-guided transthoracic needle biopsy using an 18G cutting needle. CT performed immediately after the occurrence of neurological signs showed air within the left ventricle but no air within the cerebral arteries. Radiologists must be aware of this extremely rare but potentially severe complication to provide accurate diagnosis and treatment.