Breast Biopsy

Image-guided biopsy is preferred. This can be done with a core biopsy using the stereotactic table or under ultrasound. There are many different biopsy needles available, but for all a small knick is made in the skin after injecting local. The devise is then inserted into the breast, and several cylinders of tissue are removed and placed in formalin then sent to pathology.

For stereotactic biopsies and MRI-guided biopsies, I use a vacuum-assisted device.

For ultrasound-guided biopsies, I have found both core needles and vacuum devices to be equally successful in my experience, although the scientific literature reports fewer false-negatives with the vacuum-assisted devices. I prefer to use the smaller, less expensive, less scary core needle when possible. If a lesion is very small or subtle on the sonogram, I tend to use the vacuum-assisted device to obtain larger specimens and ensure adequate sampling.

If the target for biopsy is microcalcifications, the adequacy of the specimen can be confirmed by doing a modified mammogram on the obtained specimens, to make sure that calcifications are within the tissue being sent to the pathologist. For masses and other types of biopsied lesions, it’s a bit trickier. For all biopsies, the amount of tissue collected can be visually assessed by the doctor performing the biopsy. For ultrasound-guided biopsies, the needle can be seen in real-time on the screen, and the doctor can see the biopsy needle going through the sampled lesion. For an MRI-guided biopsy, the MRI images taken with the biopsy needle in position are important for confirmation of appropriate tissue sampling. Knowing that there is always room for sampling error by the needle, most radiologists recommend six-month follow-up imaging of the biopsied breast, to confirm that the area biopsied has not changed in any significant way. In addition, when the radiologist receives the pathology report from the biopsy, he/she decides if this result from the pathologist is “concordant” with the imaging findings. If the pathology is not an acceptable answer for the radiologist’s findings (discordant), the radiologist will recommend that the lesion be taken out surgically to confirm benignity.

Over the past 20 years, the standard of care for sampling suspicious lesions in the breast has evolved from open surgical biopsies to the modern standard of minimally-invasive needle biopsy. Over many years, studies have confirmed that needle biopsies are as accurate as surgical biopsies in diagnosing breast cancer, and the needle has advantages: no operating room visit, less invasive, minimal if any scarring, no stitches, fewer complications, less expensive, quicker to perform. In addition, if cancer is diagnosed with a needle biopsy, the patient will have a greater chance of having just one surgery. (If the cancer is diagnosed on a surgical biopsy, the patient usually has to return to the operating room a second time to get all of the cancer out, and to sample the lymph nodes under the arm.) Although most biopsies can be performed with a needle, approximately 10% of biopsies must be performed surgically. The reasons include: living in a region where there are no specialists trained to perform the needle biopsy; the location of the lesion might be in a part of the breast that the needle cannot safely reach; patient inability to cooperate with positioning for the needle biopsy; medical conditions that make direct control of bleeding in the operating room necessary; a breast that is too small or large to allow for the biopsy to be performed with a needle; the presence of an implant, which might not allow for a needle biopsy without a high risk of rupturing the implant.

There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump.