Comparison of Large-Core
Vacuum-Assisted Breast
Biopsy and Excision Systems
Robin Wilson and Sanjay Kavia
2.1
Introduction
The past 30 years have seen dramatic changes in
the diagnosis and management of breast prob-
lems. Much of this change has been driven by
the quest for early diagnosis and by the wide-
spread use of imaging in the diagnosis of symp-
tomatic breast disease and for breast cancer
screening. The traditional approach of surgical
biopsy for diagnosis has now been replaced by
needle biopsy techniques that provide both
accurate and reliable diagnosis. The aims are to
prevent unnecessary surgery for benign proc-
esses and to provide detailed information on
borderline and malignant processes that allow
for prospective fully informed treatment plan-
ning (Teh et al. 1998). To achieve these aims,
specialized techniques for needle biopsy of the
breast have been developed that facilitate the
removal of sufficient amounts of tissue required
to ensure accurate diagnoses.
In the 1980s, the predominant technique for
needle sampling of the breast was fine-needle
aspiration for cytology (FNAC). The results
achieved with FNAC were encouraging but the
required reliability and acceptable sensitivity
and specificity proved to be only achievable in
Robin Wilson ()
King’s College Hospital
Denmark Hill, London SE5 9RS UK
e-mail: robinwilson@nhs.net
Renzo Brun del Re (Ed.), Minimally Invasive Breast Biopsies, Recent Results in Cancer Research 173, 23
Doi: 10.1007/978-3-540-31611-4_2, © Springer-Verlag Berlin Heidelberg 2009
2
expert centers. Even then, false-negative results
for sampling in situ disease represented by
microcalcifications and for certain types of
invasive breast cancer were disappointing. For
this reason, in the 1990s there was a trend away
from the use of FNAC to needle core biopsy
techniques. Core biopsy provides histological
material for morphological as well as cellular
assessment and the skills required for interpreta-
tion are much more widely available. The sensi-
tivity for the more elusive disease, such as
lobular invasive carcinoma, is also significantly
better. In addition, when sampling microcalcifi-
cations, core samples can be imaged to prove
retrieval of representative tissue. Overall, com-
pared to cytology, core biopsy histology pro-
vides significantly better sensitivity and positive
predictive values for both benign and malignant
disease and has a reduced rate of false-negative
results. Automated core biopsy is now accepted
as the preferred technique for breast tissue
sampling (Bassett et al. 1997; Teh et al. 1998;
Litherland 2001; Parker et al. 1996; Schueller
et al. 2008).
Using core biopsy, the vast majority of breast
abnormalities can be accurately diagnosed and
most breast lesions are amenable to ultrasound-
guided biopsy (Philpotts et al. 2003). However,
particularly for screen-detected impalpable
lesions, there remain around 5–10% of abnor-
malities where core biopsy either does not pro-
vide sufficient material for accurate diagnosis
or does not target the lesion accurately (Parker
and Burbank 1996). For these abnormalities,
either more tissue or more accurate targeting is
 24 R. Wilson and S. Kavia
necessary to achieve the tissue needed for reli-
able histopathological assessment (Kettritz et
2 al. 2003). With these two factors in mind, in the
early 1990s techniques were developed to pro-
vide both directional sampling capability and
retrieval of larger volumes of tissue (Parker
et al. 1994; Burbank 1993). These have been
further developed and refined over the past 15
years and are now in routine use for both diag-
nosis and therapeutic excision.
Two different approaches for large-core
biopsy have been developed: multiple contigu-
ous large-bore cores retrieved with the assistance
of suction (vacuum-assisted mammotomy; VAM)
and single very-large-bore core (SLCB). Both
methods can be used under X-ray (stereotactic
guidance) and ultrasound, but currently only
VAM is recommended for magnetic resonance
(MR)-guided biopsy. With these techniques, it is
now possible to retrieve sufficient tissue using
image-guided biopsy such that 98–99% accuracy
of nonsurgical diagnosis can be achieved. In fact,
so much tissue can be removed that these tech-
niques are now being used for total excision of
certain breast abnormalities. Compared to core
biopsy, VAM and very-large-core biopsy reduce
by half understaging of pathology (atypical
hyperplasia and DCIS), on average from 20 to
10%. This means that repeat biopsy and further
surgery for diagnosis and treatment are required
half as often (Liberman et al. 2000). Vacuum-
assisted biopsy is the technique of first choice
for MR-guided breast biopsy (Liberman et al.
2005; Kuhl 2007).
2.2
Large-Core Biopsy Systems: Overview
Currently one single large-core radiofrequency
biopsy system and four vacuum-assisted multi-
ple-core biopsy systems are in routine use for
breast diagnosis and excision. All of the VAM
systems are suitable for use under ultrasound,
stereotactic (upright and prone table), and MR
imaging guidance; the single intact biopsy sys-
tem is described as being suitable for ultrasound
and X-ray stereotactic-guided biopsy. All the
systems are suitable for use in the out-patient
setting with local anesthesia.
2.2.1
Single Large-Core Biopsy System
The Intact Breast Lesion Excision System
(BLES; Intact Medical Corporation Inc.) is a
breast excision system that combines the use of
vacuum and radiofrequency (RF) cutting to
remove the targeted lesion as a single specimen
(Intact Medical Corporation 2008). The probe
(or wand) (Fig. 2.1) is available in four sizes,
designed to retrieve specimens that are 10, 12,
15, and 20 mm in diameter (Fig. 2.2). The
Intact BLES probe is positioned under imaging
guidance (ultrasound or X-ray stereotaxis)
through a 6- to 8-mm skin incision and
advanced to the periphery of the area to be
excised. A cutting RF wire is activated and
advanced to cut and ensnare the target lesion
by means of four insulated struts that first
expand and then contract to surround the lesion
(Fig. 2.3). The single large sample is then
withdrawn intact through the same tract.
Vacuum is used to minimize the extent of the
RF effect on the sample excised and into the
surrounding breast tissue and to extract any
bleeding that may occur during the procedure.
The Intact BLES system is said to have the
advantage over VAM of retaining the full
histological architecture and potentially clear
margins around the area of interest and with
little RF artifact on histology (Sie et al. 2006).
It has also been reported to be associated with
reduced understaging compared to VAM (Sie
et al. 2006; Killebrew and Oneson 2006).
However, the RF function does limit its use for
lesions close to the skin or the chest wall and
for lesions in small breasts.
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 25

Fig. 2.1  The Intact disposable wand (probe) and driver

Fig. 2.2  Intact whole-tissue samples showing the size of samples achieved with the 10-, 12-, 15-, and
20-mm wands

Fig. 2.3  Diagram of how the Intact system operates

 26 R. Wilson and S. Kavia

2.2.2 rotation of the needle within the driver. The

Vacuum-Assisted Mammotomy Systems EnCor system has fully automated and program-
2 mable directional functions. Each system is
There are four systems in routine use based on described here in greater detail.
the principle of single or multiple cores using 14
to 7 French gauge needles or probes. Although
the principles of operation are similar for all of 2.2.2.1
these VAM systems, there are significant differ- Mammotome System
ences in their design, method of operation, and
attributes. Table 2.1 shows a comparison of the Mammotome (Breast Care, Ethicon ­Endo-
various attributes of these systems. All of these Surgery), the first VAM system to be developed
systems are directional, allowing sampling and originally marketed under the Biopsys name,
around a full 360-degree arc either by manual has been available since 1995, and has been
rotation of the driver or manual or automated upgraded several times since. It is a ­well-proven

Table 2.1  Comparison of VAM systems

Attribute Mammotome Vacora Atec EnCor

Drivers required Separate for US, Same for all Same for all Separate for MRI
X-ray, and MRI
Command unit Same for all Self-contained Various options Same for all
Vacuum adjustment No No Requires different Yes
units
Manual vacuum +++ No + (With lavage) +++
control
Needle gauge 11 and 8 14 and 10 12 and 9 10 and 7
Multiple core retrieval Yes No Yes Yes
Cutting method Rotating Rotating Rotating Scissor
Needle sharpness ++ + ++ +++
Core sample size ++ ++ ++ +++
Volume of tissue per ++ + +++ +++
minute
Open or closed tissue Open Open Closed Closed
collection
Smaller chamber size No No Requires different Selectable with the
Choice probe same probes
Speed of tissue ++ + +++ +++
retrieval
Needle rotation Manual only Manual only Manual only Manual or
automated
Lavage No No Full Sample chamber
Programmable ++ No No +++
functions
Biopsy site marker Yes No Yes Yes
system
Local anesthetic ++ No ++ +++
function
Probe offset Yes Yes No Yes
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 27
a b
Fig. 2.4  Mammotome biopsy probes (a) ultrasound EX system and (b) stereotactic ST system
device with more than 3 million biopsy procedures
performed worldwide and more than 200 papers
reporting various aspects of its use published in the
medical literature.
This system uses three different drivers for
stereotactic, ultrasound, and MR-guided biopsy
(Fig. 2.4a, b). All three drivers use the same
unique double-lumen probe, one lumen used for
providing the suction (at 23–25 mmHg) that
draws the sample into the biopsy chamber and
the other through which the internal rotating
cutting trocar moves to cut the sample and for
retrieval of the specimen (Fig. 2.5). All three
drivers are controlled by the same command
module (Fig. 2.6) that can be programmed to
individual preference for automated or semi-
automated function with variable pause periods
between each sample, application of suction
sequences, and “clear” mode for “dry tap”
events (Fig. 2.7). The control module can be
operated via a foot switch or a handheld control-
ler for sterotactic and MR-guided biopsy and via
buttons on the driver itself for MR- and ultra-
sound-guided procedures (Fig. 2.4). The com-
mand module provides the suction via plastic
tubing for all three uses and provides real-time
pictorial feedback of all the functions, including
the position of the cutting trocar and where in
the system suction is being applied. Suction can
be applied manually at any time during a biopsy
Fig. 2.5  Close-up view of the Mammotome probe
tip showing the double lumen system with fenes-
trations used to suck in the samples for cutting by
the rotating inner trocar. A scalpel-type blade is
embedded in the tip to ease insertion of the probe
procedure to extract any bleeding or hematoma.
Additional local anesthetic can be delivered
through a port in the vacuum tubing during a
biopsy. The needle bore and the biopsy can also
have lavage applied if blockage occurs by injec-
tion of saline through the same vacuum tubing
port.
For stereotactic biopsy, the drive for the
rotation and retraction of the cutting trocar is
via torsion cables driven from the command
unit, while for MR- and ultrasound-guided
procedures, the drive for the cutter is incor-
porated into the handheld device, allowing
for more flexible use (Fig. 2.5). The stereo-
tactic driver incorporates a spring-loaded
system that allows the needle to be fired for-
ward 20 mm into the breast while it is held in
the stereotactic holder (Fig. 2.8). In all appli-
cations, the mammotome is an open biopsy
system and each core sample must be retrieved
 28 R. Wilson and S. Kavia

Fig. 2.6  The Encor (left), Atec (middle), and Mammotome (right) control modules

Fig. 2.7  The Mammotome control module monitor showing the operating functions

from the sample collection chamber after
each biopsy (Fig. 2.9). The probes are dispos-
able and are available in two sizes (11 and 8
G) for ultrasound, stereotactic, and MR use
and are available with or without a cutting
scalpel embedded into the probe tip (Fig.
2.5). The 11-G probe provides approximately
100 mg and the 7-G probe approximately 175
mg of tissue per core sample. Special part-
ceramic probes, guides, and introducers are
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 29

a b

Fig. 2.8  The Mammotome ST system a showing the ital stereotactic system (GE Medical Systems) with
set-up for use with a lateral arm and b for biopsy of the patient in the lateral decubitus position
the inferior part of the breast using an upright dig-

Fig. 2.9  The Mammotome ST system in use for biopsy of the upper breast in the craniocaudal position
using an upright stereotactic system (GE Medical Systems) showing manual retrieval of a core sample

available to facilitate MR-guided biopsy 2.2.2.2

using standard lateral grid MR biopsy coils.
Various types of ultrasound and X-ray-visible
biopsy site markers are available for use with the
Mammotome probes, which are inserted through
the probe directly into the biopsy cavity.
Vacora
The Vacora system (C.R. Bard Inc.) was the sec-
ond device to become available for VAM (origi-
nally marketed as the BIP VacuFlash). It is
 30 R. Wilson and S. Kavia

a b
2

Fig. 2.10  The Bard Vacora vacuum biopsy system: a driver, b the system ready for use, and c a close-up
the handheld device showing insertion of the nee- view of the operating panel
dle and the self-contained vacuum system into the

unique in that it is a self-contained system incor-

porating the driver for the rotating cutting trocar
and the suction unit within the handheld unit
(Fig. 2.10a, b). The disposable probes are single-
lumen and contain a rotating cutting trocar. The
probes are available in 14- and 10-G sizes, pro-
viding approximately 50 and 150 mg of tissue
per core sample, respectively (Fig. 2.11). The
needle is directional but needs to be rotated
manually in the holder to achieve different
biopsy directions for stereotactic biopsy; for
ultrasound- and MR-guided biopsy, the com-
plete holder can be rotated for multidirectional
sampling (Fig. 2.12). The Vacora is a single-
sample system and the probe must be with-
drawn from the breast to retrieve each core
sample. For this reason a plastic guiding canula Fig. 2.11  Comparative core sample sizes achieved
is best inserted into the breast first to facilitate with 14-, 10-, and 7-G vacuum core needles
repeated insertion of the probe to the same site
in the breast. This single-sample function means extracted. It is not possible to apply manual
that it is not suitable for therapeutic excision of suction, and this limits its use when bleeding
anything other than small lesions (10 mm or occurs at the biopsy site. Additional local
less). The suction is only applied while the core anesthetic injection and biopsy site marking
is being taken and again when each core is must be delivered through the guiding plastic
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 31
Fig. 2.12  The Bard Vacora system in use for MRI-guided breast biopsy. The black line on the back of the
device indicates the direction of sampling
canula. The system incorporates a spring-loaded
firing mechanism that allows the needle to be
fired forward into the breast. The system is
simple to use because its functions are all preset
and are activated using the control panel on the
side of the device; changes to its operation
cannot be programmed by the user.
2.2.2.3
ATEC (Automatic Tissue Extraction and Collection)
The Automatic Tissue Extraction and Collection
(ATEC) system (Suros Inc.) is similar in its
function to the Mammotome ST system in that it
is driven by cables from the command unit and
uses an internal rotating cutter. However, it is a
single-bore system and the whole driver unit is
disposable (Fig. 2.13). There are three different
command modules available that deliver differing
suction levels depending or required usage (MR
only, ultrasound and stereotactic only, and all
three). The disposable handpieces are available
in two needle sizes in several lengths and sampling
chamber sizes. Twelve-gauge needles are avail-
able in 9- and 12-cm lengths, both with 20-mm
sampling chambers. The larger 9-G needles are
available in 9-, 12-, and 14-cm lengths with
the two shorter lengths available with either
20- or 12-mm sampling chambers (Fig. 2.14).
The sampling processes are preset and not
programmable by the user. All handpieces include
a closed sample collection system (Fig. 2.14).
There are two operation modes that are used
for all methods of image guidance (Fig. 2.15). In
the lavage mode the sample chamber is open
and saline is continuously instilled through the
system into the biopsy area and through the
sampling filter (Fig. 2.15). The ATEC is the only
system that uses lavage of the biopsy area.
Manual suction can also be applied (Fig. 2.15).
In the biopsy mode, the sample chamber is
closed in the resting position until the foot pedal
is used to trigger multiple rapid retrievals of
samples (averaging 150–175 mg per core). The
ATEC is the fastest-acting VAM system,
although it does not deliver more tissue per time
unit than the EnCor system (see below).
Directional sampling is achieved by rotating the
handpiece manually (Fig. 2.16). The needle of
 32 R. Wilson and S. Kavia

a b
2

Fig. 2.13  The Suros ATEC biopsy device a showing the component parts with the disposable driver and
detached closed sampling chamber and b close-up of the closed sampling chamber in place

for dense tissue and more prolonged use. The

Fig. 2.14  The Suros ATEC needles showing the 9-
and 14-cm lengths
the Suros ATEC system is not offset and this
means that there may be restrictions on its use
under stereotactic and MR guidance for lesions
close to the chest wall and in breasts with a small
compression thickness.
2.2.2.4
EnCor
The EnCor system (Senorx Corporation), like the
Vacora and ATEC, is a single-bore VAM system.
However, it differs from the other VAM systems
in many ways. The inner cutting trocar, rather
than rotating to cut the sample, uses a scissor
oscillating action that is said to be more effective
driver contains the mechanisms for driving the
cutting device and for rotating the needle (Fig.
2.17). The driver has an electrical cable and plas-
tic vacuum tubing that connects it to the com-
mand module. The same command module is
used for ultrasound-, X-ray stereotactic-, and
MR-guided biopsy (Fig. 2.6). The functions are
fully programmable by the user, including auto-
mated rotation of the biopsy sampling chamber,
which can be set for single, three (180°), six
(270°), and eight (360°) rotations in any direction
(Fig. 2.18). The automated function of the probe
rotation is particularly useful for stereotactic and
MR-guided biopsy, as the sample selection direc-
tion and extent of rotation can be preset. The
driver unit is lightweight and handheld for ultra-
sound-guided procedures (Fig. 2.19). The same
driver is attached to a holder for either prone
table or upright stereotactic use (Fig. 2.20). The
stereotactic probe holder has a spring-loaded
mechanism that allows the driver and probe to be
fired forward 20 mm into the breast.
The needle probes are available in 10- and
7-G sizes. Both have the patented tri-concave tip
design that renders the probe extremely sharp so
that it passes through all but the most dense
breast tissue with ease (Fig. 2.21). The 7-G probe
provides the largest samples of all the VAM
systems at 300 mg per core sample. The sample
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 33

Fig. 2.15  The Suros ATEC control system

Fig. 2.16  The Suros ATEC system in use for ultrasound-guided biopsy

chamber length (10 or 20 mm) for the two needle
sizes can be set at the control module and avoids
the need to select a different needle if a short
core length is required. The strength of the vac-
uum applied can also be doubled when particu-
larly dense tissue is encountered. The module
also has a preset anesthetic function that allows
for delivery of local anesthetic 360° around the
biopsy site either before or during the biopsy
procedure. The same system is used to deploy
 34 R. Wilson and S. Kavia

a b
2

Fig. 2.17  The EnCor biopsy system: a the driver

unit and disposable needle, b close-up of the
closed sample retrieval component, in place and
c detached

Fig. 2.18  The Senorx EnCor control display

2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 35

Fig. 2.19  The Suros EnCor system set up and ready for handheld use

Fig. 2.21  Close-up of the Tri-concave EnCor needle

tip

can also be used for sample radiography. There

is an optional lavage system that uses saline to
cleanse the tissue samples in the collection
chamber as they are retrieved. Like the
Mammotome and ATEC systems, the EnCor
device can be used with MRI-specific introducers
and trocars (Fig. 2.23a, b)

2.3
Fig. 2.20  The Suros EnCor system in place for ster- Indications and Limitations
eotactic-guided biopsy using a prone table
There are a number of diagnostic and therapeu-
gel and clip markers at the biopsy site (Fig. 2.22). tic situations where VAM or SLCB should be
The closed sample collection system retrieves considered as the primary technique. These
the samples in an easily removable basket that include:
 36 R. Wilson and S. Kavia

a a
2

Fig. 2.23  The EnCor system: a MRI trocar and can-

Fig. 2.22  The Encor a anesthetic control display and
ula guides and b in use for MRI-guided biopsy
b method of injection of anesthetic through the
probe system to the biopsy site

Diagnostic biopsy: – Radial scar/complex sclerosing lesion

– Sentinel lymph node
– Equivocal or failed core biopsy
– Small lesion (sub 5 mm)
– Architectural distortion
– Clustered microcalcifications 2.3.1
– Diffuse nonspecific abnormality Limitations
– Complex cyst
– Intraductal lesion The various differences in the attributes of the
– Abscess drainage large-core systems mean that some are not
suited for all of the possible indications. The
Therapeutic excision:
Vacora system has the most limitations because
– Fibroadenoma and other biopsy-proven it is a single-core device that needs to be
benign lesions removed from the breast to retrieve each sample
– Papillary and mucocele-like lesions and cannot be used to aspirate the biopsy area.
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 37

2.3.2 specific changes on imaging. All of the systems

Diagnostic Biopsy
When conventional automated core biopsy has
either failed to target the lesion or there is a bor-
derline pathological result, VAM or SLCB will
usually provide the material required to either
avoid unnecessary surgery for benign lesions or
facilitate single-stage therapeutic surgery for
malignant disease. In certain circumstances
where there is a high chance of failed sampling
with core biopsy, such as small clusters of suspi-
cious microcalcifications and very small mass
lesions, it is usually better to use VAM or SLCB
as the primary sampling technique without
attempting core biopsy first (Fig. 2.24a–c).
The same is true for circumstances where
from the outset it is recognized that larger vol-
umes of tissue will be required for diagnosis,
such as suspicion of radial scar and diffuse non-
described here are potentially suitable for these
indications, as previously described. The Intact
system is not suitable for superficial lesions and
the Vacora system is not ideal if more than
10–15 cores are likely to be necessary.
Similarly, the Intact and Vacora systems are not
ideal for sampling complex cysts, particularly
those that appear to contain a mass component.
These are best biopsied by VAM devices where
the probe remains in position in the breast
throughout the procedure and manual vacuum can
be applied. The same is true for removal of an
intraductal lesion when manual vacuum is an
important factor, as is the ability to move the sam-
pling chamber around the area without removing
the probe from the breast (Fig. 2.25a, b).
VAM systems are most widely used for
stereotactic biopsy of microcalcifications iden-
tified on mammography, and all of those

a b

Fig. 2.24  Stereotactic procedure radiograph showing a an EnCor probe in place for biopsy of calcifica-
tions, b core specimens in the sample retrieval tray, and c radiography showing calcifications success-
fully sampled
 38 R. Wilson and S. Kavia

a particularly because equivocal pathology results

and understaging of disease are much less fre-
2 quent, making repeat procedures and the need
for surgical biopsy much less common. Some
clinicians prefer to map the samples retrieved in
order to document where each sample has come
from in the breast. It is not clear what the benefit
of doing this is because it does not affect the
b subsequent management of the result and imag-
ing provides the information needed if the first
sets of samples do not contain sufficient mate-
rial. If sample mapping is required the Vacora
and Mammotome systems need to be used. For
sampling lesions close to the chest wall or when
using the lateral approach in women with small
breasts, access to the breast requires a probe
with the needle offset to avoid snagging on the
biopsy table or the chest wall. The ATEC system
does not have an offset needle.
Aspiration of breast abscess is preferred to
surgical drainage and is usually achieved by
manual suction applied through a standard nee-
Fig. 2.25  Ultrasound images showing a an intraduct dle. However, VAM systems with continuous
lesion and b an intracystic lesion, which are ideal suction capability provide the means of dealing
for VAM excision
with larger and more organized breast abscesses
when surgery would otherwise be required. The
described here are suitable for this purpose. All Vacora is not suitable for this use.
of the upright and prone biopsy mammography
systems can accommodate the VAM and Intact
systems described here (Georgian-Smith et al. 2.3.3
2002). VAM is particularly suited for this situation, Therapeutic Excision
as the vacuum assistance means that sampling is
directional and can be used to retrieve tissue at a VAM and SLCB provide an alternative to surgery
distance from the actual site of the needle. For for the removal of known benign lesions such as
core biopsy, the needle must pass through the fibroadenomas and focal fibrous lesions (Tennant
lesion for successful sampling, but with VAM et al. 2008). Large-core techniques are also being
the probe only needs to be placed close to the increasingly used instead of surgery to widely
target area. The vacuum effect is used to pull sample borderline lesions such as radial scars and
the tissue into the sampling chamber. This is papillary lesions shown on previous core biopsy
particularly useful for lesions close to the chest to have no evidence of epithelial atypia (Rosen et
wall, and behind the nipple and where the al. 2002; Carder et al. 2008). The Vacora system
cluster is more scattered. In many units now, all is only suitable for removing small lesions less
stereotactic biopsy procedures are carried out than 10 mm in diameter for the reasons outlined
using VAM systems because the retrieval results above. Similarly, the Intact system is limited by
are significantly better than core biopsy, and the size of its retrieval system, which has a maxi-
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 39
mum diameter of 20 mm. The Mammotome (7
G), ATEC (9 G), and EnCor (7 G) are all ideal for
excision of large lesions. The Mammotome sys-
tem takes longer to complete the task simply
because each sample has to be retrieved from the
sample chamber while with the other two the
samples are automatically collected by their
closed sampling systems. Many clinicians restrict
the size of lesion they are willing to attempt to
remove with VAM to around 20–30 mm. Both the
EnCor and ATEC systems will retrieve more than
1 g of tissue per minute and can be readily used to
excise lesions up to 50–60 mm in diameter.
There are also some reports of these tech-
niques being used to sample sentinel nodes prior
to surgery or primary chemotherapy treatment.
However, this indication must be considered
experimental at present. Similarly, SLCB and
VAM should not be used for excision of known
malignant lesions or borderline lesions associ-
ated with a significant risk of breast cancer
except in exceptional circumstances (Eby et al.
2008; Lee et al. 2008). In some patients who are
not medically fit for conventional treatment
(surgery and chemotherapy), SLCB and VAM
can be considered. To ensure a reasonable exci-
sion margin, the Intact system should be con-
fined to lesions no more than 10–25 mm in
diameter if a clear excision margin is to be
achieved. The VAM system can be used for
larger lesions but it must be recognized that the
excision margins will be suspect, even if sample
mapping is used.
As with all breast biopsies, ultrasound guid-
ance is the preferred guidance method whenever
possible. All of the systems described here can
be used for ultrasound-guided biopsy. The
Vacora system is usually used with a trocar. For
stereotactic biopsy, this is satisfactory because
the breast is fixed by compression. For ultra-
sound, the trocar guide system can be less effec-
tive, particularly in the large breast; since the
breast is not fixed, it can be difficult to reintro-
duce the needle to the same site for successive
biopsies. The other VAM systems remain in the
breast throughout the biopsy procedure and are
therefore easier to use in this situation. All of the
systems are light enough to be easily handheld
for ultrasound-guided use. The sharpness of the
tri-concave tip of the Encor system means that it
is more easily advanced through the breast to the
target than the other systems and is more easily
sited in the ideal position for ultrasound-guided
VAM immediately behind the lesion (Fig. 2.21).
This is particularly apparent in the dense and
fibrous breast.
2.3.4
Image-Guided Biopsy Technique
Anyone familiar with the technique for image-
guided fine-needle aspiration and conventional
core biopsy will be able to adapt easily to the
technique required for large-core biopsy because
the basic principles are the same.
Particular attention must be paid to adminis-
tration of sufficient local anesthetic for these
large-bore procedures. Significantly larger
doses are usually required than for conventional
core biopsy, particularly for excision proce-
dures and procedures done under ultrasound
guidance. The larger size and vacuum assist-
ance both mean that vessel damage is more
likely with these techniques. The use of local
aesthetic combined with adrenaline is preferred
because this reduces the chances of hematoma
and increases the time that the anesthesia is
effective. Plain local anesthetic may be pre-
ferred for the skin and subcutaneous tissues in
older patients and those with compromised
skin. For stereotactic X-ray-guided procedures,
care should be taken not to inject large volumes
of anesthetic since this can significantly displace
the target area. The biopsy-targeting process is
the same as for core biopsy with the aim of
passing the probe directly through the area to
be sampled and then biopsy around 360°.
However, unlike core biopsy, successful sampling
can be achieved if the lesion is not transfixed
 40 R. Wilson and S. Kavia
using the vacuum and directional capabilities of
the VAM systems.
2 For ultrasound-guided sampling, the anes-
thetic must be infiltrated to surround the lesion
being targeted and can be used to dissect the tis-
sue down to the lesion and to assist in separating
the target from the deep and superficial tissues.
Deep tissue anesthesia is particularly important,
as for ultrasound-guided sampling the VAM
probe is best positioned behind the lesion. Some
also advocate the use of longer-acting local
anesthetic in the deeper tissues around the target
lesion to reduce postprocedure anesthesia.
All but the Vacora system allow for further
injection of local anesthetic through the biopsy
probe into the target area (Fig. 2.22b). This can
be done as a matter of routine before the biopsy
is commenced, particularly for stereotactic pro-
cedures when the probe has been placed and dis-
placement of the lesion is then less likely to
occur. The EnCor device has a specific program
for delivering local anesthetic around the area to
be biopsied.
MR-guided biopsy can be achieved with all
of the VAM systems described (Figs. 2.12 and
2.23b). All of the manufacturers provide MR
biopsy packs that contain the necessary materi-
als to carry out the procedure using most of the
currently available MR biopsy coil systems
(Fig. 2.23a). VAM is recommended for all
MR-guided biopsies; these lesions are only vis-
ible on MR and therefore the method most
likely to successfully retrieve tissue from the
targeted area should be used (Lee et al. 2008).
2.4
Conclusions
There are a number of well-designed devices
available for vacuum biopsy and excision
biopsy. These devices enable the radiologist to
deliver a high level of diagnostic accuracy and
provide the means for minimally invasive ther-
apeutic lesion excision of benign and border-
line lesions. Accuracy approaching 99% can be
achieved, thus avoiding the need for diagnostic
surgical open biopsy in the vast majority of
cases and providing tissue samples in quanti-
ties sufficient to allow for detailed treatment
planning. The choice of vacuum biopsy system
will depend on workload, the image guidance
methods that are used, and whether lesion exci-
sion is required.
References
Bassett L, Winchester DP, Caplan RB et al (1997)
Stereotactic core needle biopsy of the breast: a
report of the joint task force of the American
College of Surgeons and College of American
Pathologists. CA Cancer J Clin 47:171
Burbank F (1993) Stereotactic breast biopsy: com-
parison of 14- and 11-guage mammotome probe.
Acta Cytol 37:461–471
Carder PJ, Khan T, Burrows P, Sharma N (2008)
Large volume mammotome biopsy may reduce
the need for diagnostic surgery in papillary
lesions of the breast. J Clin Pathol 61:928–933
Eby PR, Ochsner JE, DeMartini WB, Allison KH,
Peacock S, Lehman CD (2008) Is surgical exci-
sion necessary for focal atypical ductal hyperpla-
sia found at stereotactic vacuum-assisted biopsy.
Annu Surg Oncol 15;3232–3238
Georgian-Smith D, D’Orsi C, Morris E, Clark CF,
Liberty E, Lehman CD (2002) Stereotactic
biopsy of the breast using an upright unit, a
vacuum suction needle, and a lateral arm sup-
port. AJR 178:1017–1024
Intact Medical Corporation (2008) Percutaneous
contiguous electrosurgical breast biopsy devices.
http://www.intactmedical.com/pdf/ML087_
Rev00.pdf
Kellebrew LK, Oneson RH (2006) 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. Breast
12:302–308
Kettritz U et al (2003) Stereotactic vacuum-assisted
breast biopsy in 2874 patients: a multicentre
study. Cancer 100:245–251
2  Comparison of Large-Core Vacuum-Assisted Breast Biopsy and Excision Systems 41
Kuhl C (2007) The current status of breast MR imag-
ing. Part 1. Choice of technique, image interpre-
tation, diagnostic accuracy, and transfer of
clinical practice. Radiology 244:356–378
Lee K-M, Kaplan JB, Murray MP, Liberman L
(2008) Complete excision of the MRI target
lesion at MRI-guided vacuum-assisted biopsy of
breast cancer. AJR 191:1198–1202
Liberman L (2000) Percutaneous image-guided core
biopsy: state of the art at the millennium. AJR
174:1191–1199
Liberman L, Bracero N, Morris E, Thornton C,
Dershaw DD (2005) MRI-guided 9-guage vac-
uum assisted breast biopsy: initial clinical expe-
rience. AJR 185:183–193
Litherland J (2001) The role of needle biopsy in
the diagnosis of breast lesions. Breast 10:
383–387
Parker SH, Burbank F (1996) A practical approach
to minimally invasive breast biopsy. Radiology
200:11–20
Parker SH, Burbank F, Jackman J, Aucreman CJ,
Cardenosa G, Clink TM et al (1994) Percutaneous
large-core breast biopsy: a multi-institutional
study. Radiology 3:359–363
Parker SH, Dennis MA, Stavros AT, Johnson KK
(2006) A new breast biopsy technique. J Diagn
Med Sonogr 12:113–118
Philpotts LE, Hooley RJ, Lee CH (2003) Comparison
of automated versus vacuum-assisted methods
for sonographically guided core biopsy of the
breast. AJR 180:347–351
Rosen EL, Bentley RC, Baker JA, Soo MS (2002)
Imaging-guided core needle biopsy of papillary
lesions of the breast. AJR 179:1185–1192
Schueller G et al (2008) US-guided 14 gauge core
needle breast biopsy: results of a validation study
in 1352 cases. Radiology 248:406–413
Sie A et al (2006) Multi-center evaluation of the
breast lesion excision system, a percutaneous,
vacuum-assisted intact-specimen breast biopsy
device. Cancer 107:945–949
Teh W, Evans AJ, Wilson ARM (1998) Editorial.
Definitive non-surgical breast diagnosis: the role
of the radiologist. Clin Radiol 53:81–84
Tennant SL, Evans AJ, Hamilton LJ, James J, Lee AH,
Hodi Z, Ellis IO, Rakha EA, Wilson AR (2008)
Vacuum-assisted excision of breast lesions of
uncertain malignant potential (B3) - an alternative
to surgery in selected cases. Breast 17(6):546–549
http://www.springer.com/978-3-540-31403-5