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Interventional Procedures
Similar to the need for magnetic resonance imaging (MRI) biopsy capability in a practice that performs breast MRI, the need for tomosynthesis-guided breast biopsies in a practice that uses tomosynthesis is inevitable because there are certain lesions seen only on tomosynthesis that would be impossible to biopsy using two-dimensional (2D) stereotactic guidance. This often leads to subsequent examinations, such as ultrasound and/or MRI, on which the lesion may also not confidently be identified. In addition, some subtle lesions (low-contrast and noncalcified lesions) that can be seen on 2D mammography are problematic to biopsy when using a stereotactic technique. Tomosynthesis-guided biopsies address both of these issues.
Advantages of Tomosynthesis-Guided Biopsy
The tomosynthesis biopsy unit has many advantages over dedicated prone stereotactic biopsy units. Targets visualized by tomosynthesis alone, subtle lesions better visualized with tomosynthesis compared with 2D mammography, or lesions seen only on one mammographic or tomosynthesis view are more readily biopsied under tomosynthesis guidance ( Figs. 14.1 and 14.2 ). In addition, calcifications, architectural distortion, and small mammographic masses not seen on ultrasound may be biopsied with tomosynthesis guidance ( Fig. 14.3 ). Tomosynthesis-guided breast biopsies are cost effective and easily integrated into the daily workflow, and the upright positioning of the currently available unit improves patient access by addressing barriers to prone stereotactic biopsies, such as patient comorbidities and lesion position.
Lesion Visualization
Masses and Architectural Distortion
Tomosynthesis units use high spatial resolution digital receptors, which have better signal-to-noise and contrast-to-noise ratios than the old charge-coupled device (CCD) receptors used for currently available prone stereo devices and therefore allow accurate sampling of lesions that are not visible with the CCD detector technology ( Fig. 14.4 ). Furthermore, digital breast tomosynthesis uses the full detector size during the biopsy, as opposed to the prone stereotactic biopsy device in which there is a limited window of imaging due to a smaller compression paddle. The full detector provides a larger field of view and better orientation when targeting, which can be very helpful when performing biopsies of subtle findings. Localization of subtle lesions or one-view only findings is easier with tomosynthesis because their relative location on the orthogonal view may be determined by their depth (slice location) on the view on which they are visualized. In addition, the off-axis imaging pairs used for localization with traditional stereotaxis create a challenge when targeting subtle lesions because these lesions may be seen only on the scout view or one of the two stereotactic pair views. This issue is eliminated with the tomosynthesis scout because targeting is performed directly from the scout image.
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