In addition to board certification by the American College of Radiology, all of the breast imagers in our group have additional certification by the Federal Drug Administration (FDA) through the Medical Quality Standards Act (MQSA). This subspecialty area of our practice performs over 100,000 exams per year. Experience matters.
In the best places, the radiologist specializes in breast imaging, and that is all that he or she looks at day after day. These specialists develop a keen, eagle like ability to see small abnormalities that others might not recognize. This ability to see subtleties in breast imaging takes years to acquire. Such specialization allows these physicians to practice in breast centers, and offer early detection services to the women in the community.
We participate in ACR Breast Centers of excellence and in National Accreditation Program for Breast Centers (NAPBC). This is a rigorous process that ensures the highest levels of care for you. For more information on the importance of the NAPBC accreditation.
Our specially trained physicians are primarily interpreting imaging studies related to women’s breasts. These physicians also participate in weekly conferences where surgeons, pathologists and medical and radiation oncologists meet to discuss newly diagnosed women with breast disease problems. One woman at a time is discussed and her options for treatment reviewed. Such meetings improve communication amongst treating physicians and the direct beneficiary is you, the patient.
Everyone is at risk for breast cancer. The two most important risk factors are being female and getting older. Most women diagnosed with breast cancer have no other known factors. There is no sure way to avoid breast cancer. But, you can do things that may improve your overall health such as maintaining a healthy weight, exercising and eating a diet rich in fruits and vegetables. We don’t know what causes breast cancer. But, most women who get breast cancer have no family history of the disease. If someone in your family has had breast cancer or you are concerned about your risk, talk to your doctor. Learn about your choices and ask when to start getting mammograms.
American Cancer Society guidelines regarding breast health: Breast Self-Exam (BSE)- Women should know how their breasts normally feel. Beginning in their 20’s women should learn the benefits of BSE and should perform monthly exams. Report any breast changes promptly to you healthcare provider. Clinical Breast Exam – Women between the ages of 20 and 30 should have a breast exam by the healthcare provider every three years. Women age 40 and older should have a clinical exam annually. Mammography – Annually beginning at age 40. Mammograms may be recommended at an earlier age if there is a strong family history of breast cancer or other risk factors. For women at high-risk, the ACS guidelines advise you to discuss your risk with your healthcare provider to decide whether or not additional testing is indicated. Please see the link below for these guidelines. http://makingstrides.acsevents.org/site/PageServer?pagename=MSABC_FY09_screeningguidelines
Through MBB Radiology and our dedicated breast imaging practice, we offer the latest in breast imaging assessment and expertise. To learn more about our various imaging studies, please see below.
Women who do not have a current breast problem, lump or discharge, are candidates for digital screening mammography. This service is provided at multiple locations throughout the Jacksonville area. All women in our screening program can be assured that their screening digital mammograms are read by Dedicated Breast Imaging Radiologists who are MSQA certified and assisted by state-of-the-art equipment. The sites in which we work are all certified by the FDA. Your visit will last 15 – 30 minutes, and the screening fee also includes the interpretation of your images. It is extremely important in mammography to have your most recent exams for comparison to evaluate for changes. If your previous exam was performed at another facility, it is imperative that you bring a copy of your previous imaging studies along with the reports on the date of your screening exam. By making your previous mammograms available, your mammogram will be more accurate and in a timely manner, as we will not have to wait for the arrival of the outside images. A copy of your mammogram report will be sent to your physician and a summary report will also be mailed to you.
Digital Diagnostic Mammography is used to investigate suspicious breast changes such as a breast lump, breast pain, an unusual skin appearance, nipple retraction or discharge. It is also used to evaluate abnormal findings on a screening mammogram. As in screening mammography, if previous studies were obtained at an outside facility, it is important for you to bring a copy of the outside study along with the reports on the date of your diagnostic exam.
A marker is placed over any area of concern by the technologist prior to performing the mammogram. Additional specially focused views may also be performed as needed under the direction of the Dedicated Breast Imaging Radiologist. Patients with an abnormal screening mammogram or abnormal mammogram from an outside facility also will be scheduled for a diagnostic visit. The Dedicated Breast Imaging Radiologist may request additional specialized mammographic views to supplement the standard mammogram. The radiologist also determines whether additional information from ultrasound, MRI, other imaging, or needle biopsy is necessary.
Because of the direct involvement of the radiologist, diagnostic mammography is performed on site at one of our facilities. You will be informed of the results of your imaging at the end of your visit.
The Dedicated Breast Imaging Radiologists of MBB Radiology make extensive use of high resolution breast ultrasound in many situations. It is invaluable in evaluating children, teenagers and young women who have lumps without exposing them to radiation while their breasts are developing. At MBB, we regularly find masses in women with mammographically dense breasts, which are obscured on the mammogram. Questioned physical findings and mammographic findings are often clarified with breast ultrasound by our experienced staff. Ultrasound is also useful in evaluating lumps in the underarm or the post-mastectomy chest wall, areas which are not accessible to mammographic evaluation. The Dedicated Breast Imaging Radiologists make extensive use of ultrasound for accurate guidance of needles for cyst aspirations, needle biopsies and wire localizations for surgery.
While breast ultrasound is now being practiced more widely, it is highly operator dependent. Our staff has had extensive training and experience in the application and interpretation of high resolution breast ultrasound and performs it regularly. Our diagnostic abilities are enhanced by the performance of a targeted examination and knowledge of the mammographic findings prior to scanning the breast. This enhances our ability to find subtle lesions. Furthermore, our Breast Imaging Radiologists’ extensive years of experience in correlating imaging findings with the pathology findings of our needle biopsies enhances their diagnostic abilities in interpreting the ultrasound studies.
Breast ultrasound does not replace mammography. It is a different imaging technique that provides additional information that can be used in conjunction with mammography.
Breast cancer is the most common cancer in women, aside from skin cancer. It is the second leading cause of cancer death, after lung cancer. One in every eight women in the United States will develop breast cancer in her lifetime. This year, more than 200,000 new cases of invasive breast cancer are expected to be diagnosed among women in our country. Research is actively being done to find new tools to assist the early detection of breast cancer. One of these tools is breast MRI.
An MRI is a painless procedure in which radio waves and powerful magnets linked to a computer are used to create detailed pictures of areas inside the body without the use of radiation. Each MRI produces hundreds of pictures from side-to-side, top-to-bottom and front-to-back. Contrast (dye) is injected in one of your veins and is taken up by tumors. These pictures show the difference between normal and diseased tissue and enable doctors to determine what the inside of the breast looks like. Though widely used for many years in other areas of medicine, the MRI has only been approved by the FDA for about ten years as a supplemental tool to help diagnose breast cancer.
MRI is the most reliable method for evaluating breast implants for rupture or leakage. There is no need for injection of contrast for this type of MRI. Only in the last few years has it become a valuable addition to mammography for improved detection of breast cancer in women who are at greater risk of developing breast cancer.
WOMEN CONSIDERED HIGH-RISK INCLUDE:
Women with a risk of breast cancer greater than 20%. This is calculated through consultation with a genetic counselor with consideration of family history, number of previous breast biopsies and atypical histology and other factors.
It is important to know that while MRI of the breast is a great advance in the fight against breast cancer, it does not replace the mammogram. MRI is not an appropriate screening tool for women at average risk of developing cancer. The standard practice among healthcare providers today is that mammography plus MRI offers greater advantages to younger, very high-risk women than either method alone.
While MRI has several potential benefits in helping to investigate breast concerns, there are limitations. The two main limitations are that the cost of an MRI is several times that of a mammogram or ultrasound and that an MRI is non-specific and may lead to a benign biopsy.
Personal items that contain metal such as watches, rings, necklaces and wallets including credit cards with magnetic strips should be left at home or removed prior to the MRI scan. You will be asked to wear a hospital gown for your procedure. During the MRI, you will lie on your stomach on the scanning table. The breasts hang into a depression or hollow area on the table, which contains coils that detect the magnetic signal. The table is moved into a tube-like machine that contains the magnet. As the MRI begins, you will hear the equipment making a muffled thumping sound that will last for several minutes. There is no pain associated with an MRI. After an initial series of images has been taken, you may be given a contrast agent (dye) intravenously (by injection into the vein). The contrast agent is not radioactive; it is used to improve the ability to see a tumor. Additional images are then taken. The entire imaging session takes about 1 hour. After the exam, the radiologist will interpret the films and send a report to your healthcare provider.
American Cancer Society guidelines regarding breast health:
Molecular breast imaging (MBI) is a new FDA cleared technology used for breast imaging as an adjunct to mammography. MBI identifies tumors in dense breast tissue that are not often visible with X-ray based analog or digital mammography. MBI overcomes a known shortcoming of X-ray mammography. The X-ray breast image is incapable of differentiating between tumors and dense breast tissue. On a mammogram, both appear white. This can make it very challenging for the breast specialist to interpret the image and find potential breast disease. MBI technology is not X-ray based and therefore, has no difficulty in obtaining an image in dense breast tissue.
Here’s why: With MBI, a woman is given an injection of a short-lived radioactive agent. This material accumulates in tumor cells more than it does in normal cells. Using LumaGEM™, the industry’s first commercially available dual head radiation-detecting camera, tumors show up as hot spots on the resulting image.
In a recent Mayo Clinic study comparing MBI with mammography, MBI detected three times as many cancers in women with dense breast tissue and an increased risk of breast cancer.
Another advantage over mammography: MBI also demonstrated fewer false positives, meaning the results appear abnormal, but are noncancerous.
The LumaGEM™ MBI System is the first commercially available, FDA cleared, dual head, fully solid state digital detection imaging system utilizing eV PRODUCTS™ cadmium zinc telluride (CZT) technology used for breast imaging. This new technology provides high quality images that assist your physician in making the most accurate diagnosis.
A MBI scan with LumaGEM is quick and easy. With the dual head configuration, LumaGEM can speed up the exam time as compared to its single head competitors. A small amount of short half lived radioactive tracer (Tc-99m Sestamibi) is injected into the patient, and within just 10 minutes after injection the scan can begin. The breast is imaged in the mammography standard CC (cranial caudal) as well as the MLO (mediolateral oblique) positions. This allows for easy comparison of the original mammogram images with the LumaGEM MBI images.
Because each scan takes only minutes, the entire procedure can be completed in approximately 45 minutes and the images are immediately available for the physician’s interpretation. Most patients find the exam to be quite comfortable because unlike mammography, LumaGEM requires only light, pain-free compression.
You may be a candidate for a Molecular Imaging Exam if you have one or more of the following:
Through MBB Radiology and our dedicated breast imaging practice, we offer the latest in breast imaging procedures for the diagnosis of breast cancer.
Ultrasound is an excellent way to evaluate breast abnormalities that have been detected by mammography, Breast Self-Exam (BSE) or your healthcare provider. However, sometimes it is not possible to tell from the imaging studies alone whether a questionable area is benign or cancerous. Ultrasound-guided breast biopsy is a highly accurate way to evaluate suspicious masses within the breast that are visible by ultrasound. This method can be indicated even if the questionable area cannot be felt during breast self-exam or by clinical examination.
Ultrasound uses sound waves at very high frequency to outline specific structures of the body. The echo of the waves produces a picture called a sonogram. Ultrasound is a useful way of examining many of the body’s internal organs. It is helpful to know that the terms ultrasound and sonogram are used interchangeably. There are many ways to perform breast biopsies. For many years, surgeons removed part or all of the suspicious breast mass through an incision made in the breast. With more recent advances in breast biopsies, other methods have been added. An ultrasound-guided biopsy is just as it states – a biopsy performed by using ultrasound to locate the area in question. Unlike procedures that require the use of x-ray, ultrasound-guided biopsy requires no exposure to x-rays. This procedure is very useful when suspicious changes can be seen by mammogram and ultrasound, but no abnormality can be felt during the exam. This type of biopsy is a minimally invasive way to obtain a sample of breast tissue for further diagnosis. It is also faster and less painful than traditional surgical biopsy. It is actually the preferred biopsy method of many physicians and patients.
Your procedure will be performed by a board certified radiologist who specializes in breast imaging. The radiologist will be assisted by a technologist who is also trained in this procedure.
It is extremely important that you inform your healthcare provider regarding all medications you are currently taking. This includes vitamins, herbs and over the counter medications. There are several medications, herbs and vitamins that can cause increased bleeding. Any time the skin is penetrated there is a slight risk of bleeding. If you are taking aspirin or a blood thinner, your physician may advise you to stop your medication prior to your procedure. You will need to ask about specific instructions.
There is no special preparation required prior to having an ultrasound-guided breast biopsy. It is recommended that a comfortable two-piece outfit be worn, as you will be undressing from the waist up. When you arrive for your procedure, you will be asked to change into a hospital gown and escorted to the room where you will have your biopsy. Before you arrive, the radiologist will have studied your imaging exams to become familiar with the location of the abnormality.
You will be awake during your biopsy and should have little or no discomfort. The procedure itself will usually take less than an hour. The first part of the procedure will seem much like your original ultrasound. While lying on your back or turned slightly on your side, your breast will be scanned to find the abnormality. Then the radiologist/technician will mark your skin over the area. The radiologist will clean your breast and then numb the area with enough anesthetic to insure that you will not feel discomfort during the procedure. At times, ultrasound is also used to guide the injection of the anesthetic along the route to the mass. The anesthetic used is very similar to what is used at the dentist. There is a tiny nick on the outer skin and you may feel a sting as the medication goes in. After the anesthetic has taken effect, the radiologist will make a very small nick in the skin where the biopsy needle will be inserted. Using ultrasound guidance, a hollow core needle or vacuum assisted needle is placed in the breast, guided to the location of the mass and specimens are collected. Once the placement of the needle is confirmed, you will be asked to remain motionless while the samples are taken. Ultrasound transmits a visual image during the entire procedure, enabling the physician to view the procedure on a video screen and ensure accurate placement of the needle.
There are two methods used to collect the tissue sample. One is the core biopsy method – which is using a hollow core needle. The inside of the needle holds the tissue sample until the needle is withdrawn and is placed in a specimen container. This may be repeated multiple times. The other method uses a vacuum assisted devise (VAD). When the VAD is used, once the needle is in place a vacuum is actually used to pull the tissue into the specimen collector. Once the procedure is complete, the technician will apply pressure to the biopsy site for several minutes. Then a dressing will be applied.
Regardless of the method used for your biopsy, the tissue specimens will be sent to a pathologist for review. A pathologist is a physician who specializes in analyzing the growth of abnormal cells. A definite diagnosis should be available within a few days. Please check with your healthcare provider regarding specific expectations for your facility. Many times physicians will instruct you to make an appointment to discuss your results and decide together on the next step, if necessary.
The procedure requires little recovery time and there is no significant scarring to the breast. Most women feel fine after the procedure. Acetaminophen may be used for relief of any discomfort. An ice pack may also be helpful and should be placed inside of your bra for best results. It is a good idea to avoid exercise or strenuous activity for 24 hours following your procedure. If possible, you should go home after the procedure and relax. If you notice any bleeding, swelling, or redness or heat, notify your healthcare provider.
Your Questions are Welcome
We realize that this is a stressful time for you. As our patient, we want you to be as confident and informed about your healthcare as you can be. We hope this information has been helpful. Please do not hesitate to ask any questions you may have; we are here for you. Helping you to be as educated as possible is our goal for your healthcare.
Stereotactic breast biopsy is a minimally invasive procedure that uses special three-dimensional computerized imaging to pinpoint suspicious areas in the breast so that tissue samples may be withdrawn with a needle.
Stereotactic breast biopsy is especially useful when the abnormality can be seen on a mammogram but cannot be felt.
Stereotactic-guided breast biopsy is a simple procedure and the results are as accurate as when a tissue sample is removed surgically to determine whether a breast lump is benign (of no danger to health) or malignant (a threat to health). The procedure is performed under local anesthesia and generally takes about one hour. In general, it is not painful. Following the procedure you can usually resume normal activities.
An occasional patient has significant discomfort, which can be readily controlled by non-prescription pain medication. Infection can occur whenever the skin is penetrated, but the chance of infection requiring antibiotic therapy is minimal. Always inform your doctor, the technician or radiologist if you are pregnant or think there is a possibility you may be pregnant. You should talk with your doctor to learn if there are any other benefits and risks specific to your procedure.
A board-certified radiologist who specializes in breast imaging will perform the stereotactic-guided breast biopsy. You will be awake during the procedure and should experience little or no discomfort. You will lie on your abdomen with your breast gently placed through an opening on the table. The table will be raised and the biopsy done below the table. Your breast will be compressed using a paddle-shaped instrument, just as in a mammogram. Approximately two to three images will be taken at different angles. This allows the computer to locate the suspicious area for biopsy and assists in the placement of the biopsy needle by the radiologist.
After locating the suspicious area you may receive some local anesthetic. A very small nick (usually less than ¼ of an inch) will be made in the skin where the biopsy needle is to be inserted. Then, using the computer images as a guide, the needle will be gently inserted into the suspicious area. It is common to take multiple tissue samples from the suspicious area. Generally, the entire procedure is completed in about an hour. It is not necessary to close the tiny incision with stitches. In some cases you may experience a small amount of bruising and mild discomfort. You may be given a cold compress to help minimize swelling and tenderness of the biopsy area. Most women feel fine after the procedure. However, exercise or strenuous activity should be avoided for twenty-four hours after the procedure. It is a good idea to go home after the procedure and relax.
A pathologist will examine the tissue specimen and will report the finding to our breast center and your doctor in approximately two days. The results will be made available to you as soon as possible.
American Cancer Society guidelines regarding breast health:
Ultrasound-guided cyst aspiration is a simple procedure performed by placing an ultrasound probe over the site of a breast cyst and numbing the area with local anesthesia. The breast radiologist then places a small needle directly into the cyst and withdraws fluid.
Although ultrasound-guided cyst aspiration is a minimally invasive procedure, there is risk of bleeding whenever the skin is penetrated. Please inform our staff if you have a known bleeding problem or have been taking blood thinners, we will need to coordinate your procedure with your referring physician.
Avoid the use of underarm powder or deodorant before the procedure. Wear comfortable, two-piece clothing. An ultrasound-guided cyst aspiration usually does not require post-procedure care, but this procedure may be changed to an ultrasound-guided core biopsy if no fluid is obtained; therefore, you may want a friend or relative to accompany you to lend support and to drive you home afterwards.
Yes, you may eat a light meal before the procedure.
You will be lying on your back or slightly turned on your side. An ultrasound probe is used to locate the cyst. Your breast will be cleansed with an antiseptic. Next, the radiologist will numb the part of the breast close to the location of the cyst by injecting local anesthetic with a tiny needle. You may feel a little stick and some very brief stinging at this point. After the local anesthetic has taken effect, the radiologist, while constantly monitoring the cyst site with the ultrasound probe, guides a small needle directly into the cyst and attempts to withdraw fluid. If no fluid can be obtained, the procedure will be converted to a core biopsy.
When the procedure is completed, sterile gauze will be pressed against the area for several minutes to prevent bleeding. A band-aid will be placed over the needle puncture site
The radiologist or the nurse will then discuss what to expect after the examination and what to do when you get home. Most patients may resume their normal activities the day of the cyst aspiration.
The entire ultrasound-guided cyst aspiration should take approximately one hour or less.
If fluid is obtained during the procedure is any color other than bright red blood, it is considered benign and is discarded. If the fluid is red or bloody colored, it will be sent to Pathology for review. A diagnosis will be available within three to four business days. You will be given written instructions on how to obtain your results if the material is sent for analysis.
Ductography (also called galactography or ductogalactography) is a special type of contrast enhanced mammography used for imaging the breast ducts. Ductography can aid in diagnosing the cause of an abnormal nipple discharge and is valuable in diagnosing intraductal papillomas and other conditions. Papillomas are wart-like, non-cancerous tumors with branchings or stalks that have grown inside the breast duct; they are the most common cause of nipple discharge.
Nipple discharge can be caused by non-cancerous tumors (such as papillomas) or cancer (such as ductal carcinoma in situ, DCIS). However, the majority of nipple discharges are due to benign (non-cancerous) causes. In particular, discharges that are yellow, green, blue, or black in color are usually categorized as less suspicious. For example, blue or black discharges are often associated with benign cysts. Discharges that are bloody, colorless, or clear in color are categorized as more suspicious, but further investigation usually results in a benign diagnosis. Bilateral nipple discharge (discharge occuring from both breasts) is usually benign and does not typically require investigation with ductography or other procedures. However, all persistent discharges should be reported to a physician for evaluation.
This ductogram (or galactogram) image shows the contrast filled breast duct as white. A small, dark round nodule may be seen in the left branch of the breast duct near the bifurcation (point where the duct splits into two branches).
Most women are able to undergo ductography. However, it may be more difficult to perform ductography in:
The ductography procedure takes between 30 minutes to an hour. Patients referred for ductography most always have nipple discharge at the time of the study. Before performing the procedure, the nipple is usually cleaned and sterilized with an alcohol swab or other material to remove any dried discharge. The radiologist then applies manual pressure to the breast to elicit a fluid discharge. In patients who experience nipple discharge, there is often a “trigger” spot that causes discharge from the nipple when pressure is applied to it. After identifying the discharging duct, the radiologist feeds a small hollow needle (called a blunt-tipped cannula) into this area of the nipple while stabilizing the nipple between his or her thumb and forefinger. Usually, no force, only downward guidance, is needed to insert the cannula into the patient’s breast duct.
Once the cannula has been gently fed down the duct, a small amount of radiopaque substance (contrast media) is injected into the breast through a syringe that is connected to the cannula. The breast is then imaged with mammography; the radiopaque contrast helps enhance the duct anatomy on the resulting images. After the procedure is completed, a bandage is typically placed over the nipple to prevent fluid or dye from staining the patient’s clothes. The radiopaque contrast media is a pharmaceutical liquid made up of substances that weaken (attenuate) x-rays as they pass through the organ containing the contrast (in this case, the breast duct). The breast duct filled with contrast is then seen more clearly on the resulting mammogram image and allows the radiologist to better visualize intraductal papillomas or other abnormalities that may be present. The abnormality in the breast appears as a black nodule in the middle of the white duct.
If the radiologist has difficulty feeding the cannula into the breast duct, a local anesthetic gel or warm compress or washcloth is often used before re-attempting the procedure. Some physicians coat the tip of the cannula with anesthetic gel and also dab it on the surface of the nipple. If the cannula is still unable to be thread into the breast duct after three attempts, the procedure is typically canceled and rescheduled for one to two weeks later.
A ductogram procedure can be mildly uncomfortable but is not usually painful. A ductogram is likely to be more uncomfortable when there is not a significant quantity of nipple discharge, making it difficult for the physician to find the opening of the discharging duct. This may require “probing” to find the right duct. If there is significant fluid discharge, the needle (cannula) insertion into the breast duct is usually much easier to perform and less uncomfortable for the patient.
The syringe is used to slowly instill the contrast material through the needle (cannula) into the breast duct. This is not painful but may cause a “full” sensation similar to when the breast fills with milk during lactation (breast-feeding). If the patient feels fullness or pain during the injection of contrast, she should tell the radiologist. The goal is to completely fill the duct with contrast to get the best image possible. A sensation of pressure or “fullness” is a good sign that the duct is full and distended (enlarged). However, care should be taken to avoid overfilling because this can hide abnormalities.
In some cases, extravasation may occur during ductography. Extravasation is the flow of contrast media from the breast duct out into the surrounding breast tissue. If extravasation occurs, the cannula is removed from the breast and the patients may be treated with a pain reliever (such as ibuprofen) if necessary. The procedure is usually rescheduled for a later date, typically one to two weeks later. To help minimize the occurrence of extravasation, ductography should be performed by radiologists with significant experience with the procedure.
The ductogram (also called galactogram) may or may not identify the cause of the nipple discharge. The majority of patients who undergo ductography ultimately need surgery to treat the discharge. Surgery may involve removing a papilloma or other nodule in the breast duct. In some cases, removal of the entire ductal system may be required. For example, some patients with duct ectasia (widening and hardening of the duct) may need surgery to remove the affected duct if other treatments, such as heat compresses, do not help.
Even if the cause of discharge remains unknown after ductography, the ductogram can still help the surgeon find the affected duct so that only that duct needs to be removed. This is accomplished by mixing blue dye with the radiographic contrast so the surgeon can see the abnormal duct as blue.
Some surgeons feel that ductography is unnecessary since the patient will likely need surgery anyway. However, identifying the type of abnormality, the number of abnormalities, and their extent in the breast can be very helpful in aiding the surgeon in either removing as little tissue as necessary or in making sure to remove all of the involved tissue associated with extensive abnormalities.
Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous. A breast biopsy is performed to remove some cells—either surgically or through a less invasive procedure involving a hollow needle—from a suspicious area in the breast and examine them under a microscope to determine a diagnosis. Image-guided needle biopsy is not designed to remove the entire lesion, but most of a very small lesion may be removed in the process of biopsy. Image-guided biopsy is performed when the abnormal area in the breast is too small to be felt, making it difficult to locate the lesion by hand (called palpation). In MRI-guided breast biopsy, magnetic resonance imaging is used to help guide the radiologist’s instruments to the site of the abnormal growth.
An MRI-guided breast biopsy is most helpful when MR imaging shows a breast abnormality such as a suspicious mass not identified by other imaging techniques an area of distortion an area of abnormal tissue change
MRI guidance is used for biopsy sampling with a vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion. MRI guidance is also used for wire localization, in which a guide wire is placed into the suspicious area to help the surgeon locate the lesion for surgical biopsy.
You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing if it is loose-fitting and has no metal fasteners. Guidelines about eating and drinking before an MRI exam vary with the specific exam and also with the facility. Unless you are told otherwise, you may follow your regular daily routine and take food and medications as usual.
Some MRI examinations may require the patient to receive an injection of contrast material into the bloodstream. The radiologist or technologist may ask if you have allergies of any kind, such as allergy to iodine or x-ray contrast material, drugs, food, the environment, or asthma. However, the contrast material most commonly used for an MRI exam, called gadolinium, does not contain iodine and is less likely to cause side effects or an allergic reaction. The radiologist should also know if you have any serious health problems or if you have recently had surgery. Some conditions, such as severe kidney disease may prevent you from being given contrast material for an MRI. If there is a history of kidney disease, it may be necessary to perform a blood test to determine whether the kidneys are functioning adequately.
Women should always inform their physician or technologist if there is any possibility that they are pregnant. MRI has been used for scanning patients since the 1980s with no reports of any ill effects on pregnant women or their babies. However, because the baby will be in a strong magnetic field, pregnant women should not have this exam unless the potential benefit from the MRI exam is assumed to outweigh the potential risks. Pregnant women should not receive injections of contrast material.
Prior to a needle biopsy, you should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia. Your physician will advise you to stop taking aspirin or a blood thinner three days before your procedure. Also, inform your doctor about recent illnesses or other medical conditions.
You may want to have a relative or friend accompany you and drive you home afterward. This is recommended if you have been sedated.
Image-guided, minimally invasive procedures such as MR-guided breast biopsies are most often performed by a specially trained breast radiologist. Breast biopsies are usually done on an outpatient basis. You will lie face down on a moveable exam table and the affected breast or breasts will be positioned into openings in the table. A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm and the contrast material gadolinium will be given intravenously.
Your breast will be gently compressed between two compression plates (similar to those used in a diagnostic MRI exam), one of which is marked with a grid structure. Using computer software, the radiologist measures the position of the lesion with respect to the grid and calculates the position and depth of the needle placement. A local anesthetic will be injected into the breast to numb it. A very small nick is made in the skin at the site where the biopsy needle is to be inserted.
The radiologist then inserts the needle, advances it to the location of the abnormality and MR imaging is performed to verify its position. Depending on the type of MRI unit being used, you may remain in place or be moved out of the center or bore of the MRI scanner.
Tissue samples are then removed using one of three methods:
After this sampling, the needle will be removed. If a surgical biopsy is being performed, a wire is inserted into the suspicious area as a guide for the surgeon. A small marker may be placed at the site so that it can be located in the future if necessary. Once the biopsy is complete, pressure will be applied to stop any bleeding and the opening in the skin is covered with a dressing. No sutures are needed. A mammogram may be performed to confirm that the marker is in the proper position. This procedure is usually completed within 45 minutes.
You will be awake during your biopsy and should have little or no discomfort. Most women report little or no pain and no scarring on the breast. Some women find that the major discomfort of the procedure is from lying on their stomach for the length of the procedure, which can be reduced by strategically placed cushions. When you receive the local anesthetic to numb the skin, you will feel a slight pin prick from the needle. You may feel some pressure when the biopsy needle is inserted. The area will become numb within a short time. You must remain still while the biopsy is performed. As tissue samples are taken, you may hear clicks from the sampling instrument. If you experience swelling and bruising following your biopsy, you may be instructed to take an over-the-counter pain reliever and to use a cold pack. Temporary bruising is normal.
You should contact your physician if you experience excessive swelling, bleeding, drainage, redness or heat in the breast. If a marker is left inside the breast to mark the location of the biopsied lesion, it will cause no pain, disfigurement or harm. You should avoid strenuous activity for 24 hours after returning home, but then usually will be able to resume normal activities.
A pathologist examines the removed specimen and makes a final diagnosis. Depending on the facility, the radiologist or your referring physician will share the results with you. Follow-up examinations are often necessary, and your doctor will explain the exact reason why another exam is requested. Sometimes a follow-up exam is done because a suspicious or questionable finding needs clarification with additional views or a special imaging technique. A follow-up examination may be necessary so that any change in a known abnormality can be detected over time. Follow-up examinations are sometimes the best way to see if treatment is working or if an abnormality is stable over time.
Manufacturers of intravenous contrast indicate mothers should not breastfeed their babies for 24-48 hours after contrast medium is given. However, the American College of Radiology (ACR) note that the available data suggest that it is safe to continue breastfeeding after receiving intravenous contrast. For further information please consult the ACR Manual on Contrast Media and its references.
MRI-guided tissue sampling is limited by the position of the abnormality in the breast. Breast lesions located in the back of the breast or small abnormalities can be difficult or impossible to accurately target using MR. Breast biopsy procedures will occasionally miss a lesion or underestimate the extent of disease present. If the diagnosis remains uncertain after a technically successful procedure, surgical biopsy will usually be necessary. The MR-guided breast biopsy method cannot be used unless the mass can be seen on an MRI exam. Calcifications within a cancerous nodule are not shown as clearly with MR as with x-rays. Small lesions may be difficult to target accurately by MR-guided breast biopsy. The widespread use of this technique is limited by its high cost, availability, and length of the procedure. MR-guided biopsy should not be considered if the lesion can be seen on mammography or on ultrasound, where the biopsy can be performed more easily with less patient discomfort. In those cases, stereotactic biopsy or ultrasound-guided biopsy are the more appropriate methods of tissue sampling.
At this point, your healthcare provider or team has determined that there is an abnormality in your breast that is cancerous. You have had so many decisions to make with your new-found cancer and now there may be another one. We are hopeful that the information found in this brochure will be helpful in your decision-making process.
Standard treatment for breast cancer usually involves removing a breast tumor by one of two ways – lumpectomy or mastectomy. Lumpectomy is the removal of a small portion of the breast. It is considered breast conservation therapy because it only requires removal of the tumor itself and a margin of tissue around it. This allows you to keep a portion of your breast tissue. Mastectomy involves removal of the entire breast and sometimes the tissue around the breast. Normally, breast tissue drains into the lymph nodes beneath the arm pit by several connecting channels. The lymph system is an important part of the body that produces and stores lymphocytes (cells that fight infection), drains fluid from tissues throughout the body and aids the immune system. Just like normal tissues drain into the lymph nodes to remove waste, cancer cells do too. When cancer cells travel from a tumor in the breast, their first stop is most often the lymph nodes in the axilla (underarm). The presence of cancer in the lymph nodes has long been considered the single most reliable indicator of cancer that has spread. Until now, most of the lymph nodes in the underarm (axilla) closest to the cancerous breast have also been removed to examine them for spread of the cancer. This is referred to as an axillary lymph node dissection or just axillary dissection. The removal of these lymph nodes causes a change in the structure and function of the lymphatic system and may create side effects in patients post-operatively (after surgery). With fewer lymph nodes to drain lymph fluid, the fluid can back up causing painful swelling (lymphedema) in the arm. This condition can be persistent and interfere with activities of daily living. Patients with prior axillary lymph node dissections are also at an increased risk for infection in that arm.
Originally developed for use with melanoma, sentinel node biopsy was first reported for breast cancer use in 1993. Through years of research, we have learned that when breast cancer spreads from the primary tumor to the lymph nodes it appears in some nodes before spreading to others. These are known as sentinel nodes or first nodes. Doctors and patients are now wrapping their eager arms around a new technique of biopsying only the sentinel node(s). With the ability to biopsy only the sentinel node(s) for metastasis (spread of cancer), doctors are able to prevent many women with breast cancer from having more extensive surgery. If the sentinel node is free of cancer, nodes further “downstream” presumably will be cancer free as well and can be left alone. Only one-third of women with breast cancer will have cancer in the lymph nodes. Sentinel node biopsy appears to lower a woman’s chance of developing lymphedema as much as half, in comparison with axillary node dissection. The recovery time for sentinel node biopsy dissection is also much shorter and less painful than with axillary dissection if less than 5 lymph nodes are removed. In addition, it allows more accurate staging of the cancer while leaving the unaffected nodes behind to continue their job of draining fluids from the tissue.
You will typically be given detailed instructions by your surgeon, the hospital surgery center and the anesthesiologist prior to the day of your procedure. You will be informed to avoid eating or drinking anything after midnight if you are scheduled for surgery the following morning or afternoon.
When you arrive at the facility on the day of your procedure, you will be asked to sign a consent form which states that you understand the procedure being performed, the risks involved and that you agree to have the procedure. You will then be directed to the changing area to undress from the waist up and put on a hospital gown. Unless directed otherwise, you may leave on your pants and socks until you are actually ready for surgery. For this reason, it is best to wear a two piece outfit. The actual removal of the sentinel node(s) takes place in the operating room, but more than likely you may be asked to report to the breast center first for the injection. Then you may proceed to nuclear medicine for imaging.
A sentinel node biopsy involves mapping the lymphatic system to find the sentinel node. This is referred to as sentinel node mapping. It is done with the use of a mildly radioactive tracer and a blue dye.While you are in Nuclear Medicine the radioactive tracer will be injected at the tumor site and near the nipple to follow the path of the lymphatic fluid from the tumor to the sentinel node. It is important to explain that during the injection of the radioactive material, local anesthetic cannot be used because it is not known how it might affect or react with the radioactive tracer. However, the actual injection of the tracer results in only mild discomfort. At this point you are ready to go to surgery for the actual biopsy procedure. Once in the operating room, the surgeon usually injects blue dye around the tumor site and the lymph fluid will also carry it to the sentinel node. A small incision is made and the surgeon looks for the lymph node that is stained with the blue dye and may use a special tiny probe that will tell with an audible signal precisely which node(s) contains the radioactivity. The node(s) is removed and sent to the pathologist for examination under a microscope for cancer cells.
After surgery, your urine will be blue or green-blue for 24-48 hours. Your breast tissue around the injection sites will be blue for weeks, maybe even months. Both of these are harmless to you. You will have a small scar from the incision to remove the lymph node. More than likely it will be under your arm. For the first day or two after surgery you may have some swelling and mild discomfort. Should you notice any unusual drainage, a foul odor, redness or warmth at the site or if you develop a fever of 100° or above, please notify your healthcare provider. Not all women with breast cancer are candidates for sentinel node biopsy.
The following women are poor candidates:
Sentinel node biopsy (SLNB) is not for everyone. While some patients are overwhelmingly enthusiastic about this new procedure, it is important for you to discuss the pros and cons for you as an individual with your healthcare provider or cancer care team. It is also important that you feel confident that your surgeon is well experienced in sentinel node biopsy, since it is a fairly new technique. Last, you should be aware that there is a small chance (less than 1 in 10 cases) that the results of the sentinel node biopsy can be inaccurate; that is, there is not cancer in the sentinel nodes but cancer exists in other axillary lymph nodes.
Occasionally it will be necessary for the radiologist to recommend needle localization and surgical excision. This can occur when the area on a mammogram is in a part of the breast which is too thin for a stereotactic core biopsy or if it is too far posterior or too close to the nipple. Sometimes the area is too broad for accurate tissue sampling. Occasionally, a needle biopsy will help demonstrate an area that has borderline cells or is malignant and needs surgical removal.
In order for your surgeon to remove the area of breast tissue that contains the suspicious area, he or she will need a guide to show the exact location of the abnormality. Needle localization is most often performed immediately prior to surgery on patients who are having surgical breast biopsies or lumpectomies. The breast localization procedure will result in precise pinpointing of the abnormality thereby increasing your surgeon’s ability to remove all of the abnormal tissue while reducing the removal of healthy tissue It also reduces the length of time you are in surgery.
The needle localization may be performed either under ultrasound guidance or mammographic guidance, depending on which type of imaging best shows the abnormality. The most common way to perform needle localization is to use mammographic guidance. As in the mammogram, your breast will be placed between specially designed compression plates. Before the localization procedure, an x-ray will be taken from different views to determine the location of the abnormality. A needle will be inserted into your breast to mark the exact position of the abnormality. Once properly located, the needle will be removed leaving a thin wire as a guide for your surgeon. If done by ultrasound guidance, ultrasonic waves are used to locate the abnormality. Once identified, the procedure for marking the area is the same as the procedure using mammographic guidance.
The radiologist will numb the outer skin of your breast and the tissue deeper within your breast with a small needle. The injection of anesthetic may sting for a few seconds. This anesthetic is similar to what one might have at a dentist’s office. Once the anesthetic has taken effect, you should not feel any pain during the placement of the needle. You may feel the pressure of the compression paddles but it shouldn’t be any worse than with mammography. Once the localization procedure is complete patients rarely experience discomfort.
A radiologist who is trained in reviewing mammograms and breast ultrasounds will perform the procedure. This radiologist is also specially trained in performing needle localizations. The radiologist will be assisted by a technologist who is trained in this procedure. The technologist will be taking the films before and after the procedure. There may or may not be a nurse in the room at the time of the procedure.
***On the day of your breast needle localization, please do not wear any lotions, powders or deodorant around your breasts or under arms.
A breast needle localization takes approximately one hour. Most often, you will be asked to arrive at the hospital on the day of your biopsy surgery early enough to have the needle localization done prior to your surgery. The procedure will be done in the radiology department unless you are instructed otherwise. Be sure to follow instructions regarding eating and drinking prior to surgery.
Before the procedure you will need to remove your clothing from the waist up and put on a hospital gown. The technologist will help position you in a special chair. Once positioned, the mammography technologist will take an x-ray of your breast. The procedure is similar to the one used for a mammogram. This helps determine the location of the abnormality. The radiologist will then numb the breast tissue with local anesthetic. You will feel a pinch or a tiny pin prick at this time. The radiologist will then insert the localization needle toward the exact location of the abnormality. Another x-ray will then be taken to confirm the location of the needle. Since your radiologist will want to pinpoint the exact location of the abnormality for your surgeon, the needle may need to be repositioned. If the needle is repositioned, another x-ray will need to be done to verify placement. When the radiologist has determined that the abnormality has been targeted, a very small guide wire will be inserted down through the inside of the needle to mark the position of the abnormality. A small hook at the end of the wire keeps it in place in the breast and the needle will be removed. This means that there will be a wire sticking out of your breast, which can look somewhat strange. Often, patients would rather not look at the area until a dressing is placed over the wire. Once the wire is taped to your skin you can now relax. Two final films will be taken to show your surgeon the exact location of the wire and the procedure is complete. The breast localization procedure is the way your radiologist helps your surgeon find the abnormal tissue. This also reduces the length of surgery and minimizes the removal of health tissue. You will then proceed to surgery.
When your surgery is over, you will wake up during the recovery phase. The time spent in recovery varies with each individual. The average amount of time is one to two hours. Once you are able to eat, drink, and go to the rest room, you will be discharged.
Once at home, it is important for you to follow your doctor’s specific instructions regarding activity. Postoperative pain is usually minimal and resolves within a few days. Pain medication may or may not be prescribed. You may return to work as early as the following day providing your job is not physically demanding. Heavy lifting should be avoided for 1 to 2 weeks following the procedure. The incision should be completely healed within one month.
If you have any questions about the procedure, ask your radiologist or the technologist. Your complete understanding of this procedure is important to them.
Anyone with a Personal or Family History of:
At our hospital facilities, breast cancer risk assessment and genetic counseling are available through their Genetic Risk Assessment programs. Patients may be referred for high-risk screening by a physician or may call our hospital breast centers directly (self-referral) to set up an appointment.
A bone density test determines if you have osteoporosis — a disease that causes bones to become more fragile and more likely to break. In the past, osteoporosis could be detected only after you broke a bone. By that time, however, your bones could be quite weak. A bone density test makes it possible to know your risk of breaking bones before the fact. A bone density test uses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones that are most commonly tested are located in the spine, hip and forearm.
Doctors use bone density testing to:
The higher your bone mineral content, the denser your bones are. And the denser your bones, the stronger they generally are and the less likely they are to break. Bone density tests are not the same as bone scans. Bone scans require an injection beforehand and are usually used to detect fractures, cancer, infections and other abnormalities in the bone. Although osteoporosis is more common in older women, men also can develop the condition.
Regardless of your sex or age, your doctor may recommend a bone density test if you’ve:
Limitations of bone density testing include:
If you are having the test done at a medical center or hospital, be sure to tell your doctor beforehand if you have recently had a barium exam or contrast material injected for a CT scan or nuclear medicine test. These contrast materials might interfere with your bone density test.
Bone density tests are usually done on bones that are most likely to break because of osteoporosis, including:
Your bone density test results are reported in two numbers: T-score and Z-score.
Your T-score is your bone density compared with what is normally expected in a healthy young adult of your sex. Your T-score is the number of units — called standard deviations — that your bone density is above or below the average.
What your score means:
Your Z-score is the number of standard deviations above or below what is normally expected for someone of your age, sex, weight, and ethnic or racial origin. If your Z-score is -2 or lower, it may suggest that something other than aging is causing abnormal bone loss. If your doctor can identify the underlying problem, that condition can often be treated and the bone loss slowed or stopped.
This examination is offered throughout the MBB practice. Please contact your physician for a referral.
Baptist Health (904) 202-7313
Memorial Hospital Jacksonville (904) 399-6348
Orange Park Medical Center (904) 639-8427
When a patient is diagnosed with cancer he or she can become overwhelmed. Undergoing various treatments and dealing with healthcare professionals from different specialties like radiologists, pharmacists, and oncologists can be a lot to handle. Because of this, a new nursing sub-specialty has developed—the nurse navigator. A nurse navigator will offer medical guidance, act as a support group, and “walk patients and their families through the cancer treatment process.” Navigators who work with cancer patients already have nursing experience, but take navigation-specific classes to become fully qualified. Although navigators are new to the healthcare industry, programs have been started in hospitals across the United States.
The roles of a nurse navigator include:
If you have been diagnosed with breast cancer at one of our facilities, please call the respective facility to learn more:
Baptist Health: (904) 202-7460
Memorial Health Care: (904) 399-6348
Orange Park Medical Center: (904) 639-8427