Bleeding Complications After Breast Core-needle Biopsy-An Approach to Managing Patients on Antithrombotic Therapy

Hemorrhagic Complications Following Ultrasound-Guided Breast Biopsy: A Prospective Patient-Centered Study

OBJECTIVE

We aimed to evaluate the clinical and imaging factors associated with hemorrhagic complications and patient discomfort following ultrasound (US)-guided breast biopsy.

MATERIALS AND METHODS

We prospectively enrolled 94 patients who were referred to our hospital between June 2022 and December 2022 for US-guided breast biopsy. After obtaining informed consent, two breast radiologists independently performed US-guided breast biopsy and evaluated the imaging findings. A hemorrhagic complication was defined as the presence of bleeding or hematoma on US. The patients rated symptoms of pain, febrile sensation, swelling at the biopsy site, and dyspnea immediately, 20 minutes, and 2 weeks after the procedure on a visual analog scale, with 0 for none and 10 for the most severe symptoms. Additional details recorded included those of nausea, vomiting, bleeding, bruising, and overall satisfaction score. We compared the clinical symptoms, imaging characteristics, and procedural features between patients with and those without hemorrhagic complications.

RESULTS

Of 94 patients, 7 (7%) developed hemorrhagic complications, while 87 (93%) did not. The complication resolved with 20 minutes of manual compression, and no further intervention was required. Vascularity on Doppler examination (P = 0.008), needle type (P = 0.043), and lesion location (P < 0.001) were significantly different between the groups. Patients with hemorrhagic complications reported more frequent nausea or vomiting than those without hemorrhagic complications (29% [2/7] vs. 2% [2/87], respectively; P = 0.027). The overall satisfaction scores did not differ between the two groups (P = 0.396). After 2 weeks, all symptoms subsided, except bruising (50% 2/4 in the complication group and 25% [16/65] in the no-complication group).

CONCLUSION

US-guided breast biopsy is a safe procedure with a low complication rate. Radiologists should be aware of hemorrhagic complications, patient discomfort, and overall satisfaction related to this procedure.

Clinically significant bleeding complications of percutaneous breast biopsy: 10-year analysis and a proposed management algorithm

PURPOSE

Bleeding is a well-known risk of percutaneous breast biopsy, frequently controlled with manual pressure. However, significant bleeding complications may require further evaluation or intervention. Our objectives were to assess the rate, type, and periprocedural management of significant bleeding following percutaneous breast biopsy and to evaluate the success of any interventions.

METHODS

We retrospectively reviewed percutaneous breast biopsies at our institution over a 10-year period with documented post-biopsy bleeding complications in radiology reports. Patients were included if bleeding required intervention (interventional radiology [IR], surgery, or other), imaging follow-up, or clinical evaluation for symptoms. Additional data included patient demographics, anticoagulation, history of bleeding diathesis, biopsy details, bleeding symptoms, histopathology, and intervention details, if applicable.

RESULTS

Of 5820 unique patients who underwent percutaneous biopsy, 66 patients (66/5820; 1.1%) comprising 71 biopsy cases met inclusion for clinically significant bleeding with 5/71(7.0%) requiring surgery, 9/71(12.7%) requiring IR intervention, and 57/71(80.3%) requiring lower-acuity intervention including prolonged observation (5/57;7.0%), overnight admission (4/57;5.6%), aspiration (4/57;5.6%), lidocaine and suture (2/57;2.8%), primary care visit (7/57;10.0%), blood transfusion (1/57;1.4%), emergency room visit (6/57;8.5%), surgery consult (8/57;11.3%), IR consult (2/57;2.8%), and follow-up imaging (22/57;31.0%). Most patients requiring intervention by surgery or IR had acute signs of bleeding immediately after biopsy while most patients with delayed signs of bleeding required lower-acuity interventions.

CONCLUSION

Clinically significant bleeding is extremely rare after percutaneous breast biopsy and is most often managed non-surgically. Developing an institutional algorithm for management of bleeding complications that consults IR before surgery may help decrease the number of patients managed surgically.

Reducing False Negatives in Biopsy of Suspicious MRI Findings

Breast MRI is a highly sensitive imaging modality that often detects findings that are occult on mammography and US. Given the overlap in appearance of benign and malignant lesions, an accurate method of tissue sampling for MRI-detected findings is essential. Although MRI-directed US and correlation with mammography can be helpful for some lesions, a correlate is not always found. MRI-guided biopsy is a safe and effective method of tissue sampling for findings seen only on MRI. The unique limitations of this technique, however, contribute to false negatives, which can result in delays in diagnosis and adverse patient outcomes; this is of particular importance as most MRI examinations are performed in the high-risk or preoperative setting. Here, we review strategies to minimize false negatives in biopsy of suspicious MRI findings, including appropriate selection of biopsy modality, use of meticulous MRI-guided biopsy technique, management after target nonvisualization, assessment of adequate lesion sampling, and determination of radiology-pathology concordance. A proposed management algorithm for MRI-guided biopsy results will also be discussed.

Current Practices in Anticoagulation Management for Patients Undergoing Percutaneous Image-guided Breast Procedures

Objective

Given variability in how practices manage patients on antithrombotic medications, we undertook this study to understand the current practice of antithrombotic management for patients undergoing percutaneous breast and axillary procedures.

Methods

A 20-item survey with multiple-choice and write-in options was emailed to 2094 active North American members of the Society of Breast Imaging (SBI) in March 2021. Data were collected anonymously and analyzed quantitatively, with free-text responses categorized by themes.

Results

Three-hundred twenty-six of 2094 members (15.6%) completed the survey. Eighty-seven percent (274/313) reported having a policy for managing antithrombotic medications. Fifty-nine percent (185/312) reported routinely withholding medications before biopsy, more commonly in the Northeast and South (P = 0.08). Withholding of medications did not vary by lesion location (182/308, 59%, breast vs 181/308, 58.7%, axillary; P = 0.81). Respondents were statistically more likely to withhold medications if using a vacuum-assisted device for all classes of antithrombotic medications (P < 0.001). Up to 50.2% (100/199) on warfarin and 33.6% (66/196) on direct oral anticoagulants had medications withheld more stringently than guidelines suggest.

Conclusion

Based on a survey of SBI members, breast imaging practices vary widely in antithrombotic management for image-guided breast and axillary procedures. Of the 60% who withhold antithrombotic medications, a minority comply with recommended withhold guidelines, placing at least some patients at potential risk for thrombotic events. Breast imaging radiologists should weigh the risks and benefits of withholding these medications, and if they elect to withhold should closely follow evidence-based guidelines to minimize the risks of this practice.