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VAE on-line content.

Vacuum assisted biopsy (VAB) was first introduced in 1995 by Fred Burbank and Mark Retchard to overcome the challenges with FNA (fine needle aspiration) and core biopsy. Despite being introduced in the mid-1990s, it took about 10-15 years for wider adoption within the breast imaging community. The concept of vacuum assisted excision stemmed from VAB.

The difference between VAB and VAE is that VAB is where the biopsy is being performed to establish a diagnosis while VAE is where a diagnosis has been made and the decision is to perform a further biopsy to either sample a larger area (aiming for about 4 grams) or to excise the lesion.

The Marmot review¹ played an important role in the adoption of VAE for the management of high risk/B3 lesions and supporting trials such as the SMALL Trial². The Marmot review¹ concluded that breast screening saves lives and that for every 10 000 UK women invited to screening from age 50 for 20 years, about 681 cancers will be found, of which 129 will represent over-diagnosis, and 43 deaths from breast cancer will be prevented.

Over-diagnosis was defined¹ as a cancer–invasive or non-invasive–diagnosed by screening that would not have presented during a woman’s lifetime. The focus was initially over-diagnosis but quickly this was recognised as being inevitable and the focus quickly shifted to minimising overtreatment. Following the Marmot review, a group was set up to look at minimising treatment of high risk/B3 lesions in the UK breast screening programme. This was a multi-disciplinary group consisting of radiologists, pathologists, and surgeons. The NHS Breast Screening multidisciplinary working group guidelines for the diagnosis and management of breast lesions of uncertain malignant potential on core biopsy (B3 lesions) were endorsed and adopted by the NHS Breast Screening programme in 2016³ and the guidelines were published in 2018⁴. Subsequently data was published on the impact in 2022⁵, showing that VAE was a safe alternative to surgery for this group.

Continuing with the theme of minimising overtreatment, this was then extended at looking at good prognostic tumours (grade 1, ER positive and HER2 negative). The SMALL Trial⁶: Open surgery versus minimally invasive vacuum-assisted excision for small screen-detected breast cancer–a UK phase III randomised multi-centre trial was set up. This trial is looking to see if small (≤15 mm), grade 1, ER and PR positive and HER2 negative cancers can be treated with VAE rather than surgery.

The future is exciting as clinicians are using existing tools such as VAB/VAE, which are widely available, and repurposing then to help improve the patient pathway and minimise overtreatment.

The term VAE can be categorised as a diagnostic VAE or therapeutic VAE. Diagnostic vacuum assisted excision^3,4,5,7 or extended vacuum assisted biopsy (DVAE or EVAB) is defined as taking a large volume of tissue (equating to about 4 grams) for further sampling of an area, accepting that if a lesion is small (≤15 mm), it may be excised in its entirety. The main aim is representative sampling of the area that would equate to a surgical diagnostic biopsy.

Therapeutic vacuum assisted excision (TVAE) is defined as using vacuum biopsy to excise a cancer–the aim would be to excise the lesion. The lesion would be excised piecemeal and therefore margins cannot be assessed with TVAE histologically. Complete excision will need to be determined by the operator performing the TVAE and post-excision imaging.

• Excision of benign lesions such as fibroadenomas^8,9
• Management of high-risk lesions/B3 lesions^3,4,5,7,10
• Excision of good prognostic tumours^2,6 in the context of a trial

DVAE/EVAB or TVAE can be performed under ultrasound, X-ray or MRI guidance. The modality of choice is determined by the modality in which the lesion is best visualised and most readily accessible with the vacuum biopsy device⁷.

Performing a DVAE/EVAB – tips for success

1. Review all baseline imaging–mammography/tomosynthesis/ultrasound and MRI if performed.
2. Identify the abnormality for biopsy and if there is a marker clip already in place–is the marker clip adequately positioned?
3. Adequate analgesia is important to ensure patient compliance during the biopsy. Normally 20 mL of 1% Xylocaine with adrenaline is used. It is important to create a cylinder of anaesthesia around the lesion to ensure the surrounding tissue is adequately anaesthetised, including tissue above and below the lesion.
   • a. If performed Mammography- guided or MRI-guided, then this means giving analgesia in a clock face fashion at 12, 3, 6, and 9 o’clock. The anaesthesia also needs to extend from the skin to the lesion and beyond the lesion as the tip of the needle will be within normal breast tissue.
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   • b. If performed under US guidance, ensure that analgesia is given from the skin to the lesion and beyond the lesion. Use local anaesthesia medial, lateral, and inferior to the lesion. Ensure no gas is within the syringe and then administer a thin layer of anaesthesia above the lesion. This is important because on US the trough of the biopsy needle will lie beneath the lesion. The trough of the biopsy needle will be rotated, creating a semi-circle to ensure sampling the whole lesion. The superior aspect will include normal breast tissue and it is important that this is anaesthetised.
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4. Ensure the patient is in a comfortable position such that they can stay still for at least 20 minutes. Ensure, as the operator, you are in a comfortable position.
5. Post-clip mammogram is important to assess clip position and to see if the original lesion is still visible or has been fully excised. Sometimes it is difficult to assess due to haematoma or post-biopsy changes and therefore the mammogram needs repeating 4-6 weeks later.

Pre-VAE procedure

Post-VAE procedure

Samples

The most common complication is post-biopsy bleeding or haematoma. This can be minimised by appropriate compression of the area biopsied for 10 minutes, ensuring that the biopsy tract is not inadvertently being compressed, to ensure expression of the residual haematoma. If after 10 minutes bleeding persists, apply compression for another 10 minutes and finally apply a pressure bandage on the biopsy site.

Delay the post-clip mammogram if the patient bleeds beyond 10 minutes.  Perform a few weeks later, ideally when the patient is coming back for follow up.