Needle Biopsy

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. 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.

A stereotactic biopsy is a form of needle biopsy. "Stereotactic" refers to method in which we will image the finding, in order to guide the needle. A stereotactic biopsy is the way we biopsy a mammogram finding, it is not used for ultrasound or MRI findings. If the finding is a cluster of calcifications found on mammography, this will be the preferable mode of biopsy. Nodules are often seen both on mammography and sonography and then an ultrasound guided biopsy is faster, cheaper, and more comfortable for the patient. When we refer to a stereotactic biopsy most facilities are using a vacuum-assisted devise (needle) but this is not part of the definition of stereotactic. A vacuum-assisted devise is particularly beneficial when sampling calcifications, as quantity of tissue retrieved will contribute to accuracy of the diagnosis. This is not necessarily the case for masses. A stereotactic biopsy is a form of needle biopsy. "Stereotactic" refers to method in which we will image the finding, in order to guide the needle. A stereotactic biopsy is the way we biopsy a mammogram finding, it is not used for ultrasound or MRI findings. If the finding is a cluster of calcifications found on mammography, this will be the preferable mode of biopsy. Nodules are often seen both on mammography and sonography and then an ultrasound guided biopsy is faster, cheaper, and more comfortable for the patient. When we refer to a stereotactic biopsy most facilities are using a vacuum-assisted devise (needle) but this is not part of the definition of stereotactic. A vacuum-assisted devise is particularly beneficial when sampling calcifications, as quantity of tissue retrieved will contribute to accuracy of the diagnosis. This is not necessarily the case for masses.

For almost all findings found by imaging (mammography, sonography, or MRI) a needle biopsy is the preferred next step. Firstly, most of the findings (nodules and calcifications) which we identify are benign, so surgery can be avoided. Sometimes we are quite certain that the finding is malignant but still a needle biopsy is performed so that the surgeon performs surgery knowing what s/he is going after. For example, if the surgery is removal of a biopsy-proven cancer (lumpectomy) then they should remove larger margins. In this day and age it is fairly unusual to go to surgery to remove a nodule that the surgeon does not know what it is. Furthermore, if the diagnosis of cancer has been established in advance, then the surgeon will do the evaluation of axillary lymph nodes (sentinal node biopsy) at the time of the initial surgery (a one-step procedure). Also, they will be planning for the best cosmetic result.

When a lump is felt, but no abnormality is identified on imaging studies, a surgeon may still opt to remove it. In that scenario s/he does not know what they will find at surgery. A needle biopsy may or may not be done first. If a needle biopsy is being done, it is based on the palpable finding (feeling the lump) this would be done by the surgeon, not the radiologist. For almost all findings found by imaging (mammography, sonography, or MRI) a needle biopsy is the preferred next step. Firstly, most of the findings (nodules and calcifications) which we identify are benign, so surgery can be avoided. Sometimes we are quite certain that the finding is malignant but still a needle biopsy is performed so that the surgeon performs surgery knowing what s/he is going after. For example, if the surgery is removal of a biopsy-proven cancer (lumpectomy) then they should remove larger margins. In this day and age it is fairly unusual to go to surgery to remove a nodule that the surgeon does not know what it is. Furthermore, if the diagnosis of cancer has been established in advance, then the surgeon will do the evaluation of axillary lymph nodes (sentinal node biopsy) at the time of the initial surgery (a one-step procedure). Also, they will be planning for the best cosmetic result.

When a lump is felt, but no abnormality is identified on imaging studies, a surgeon may still opt to remove it. In that scenario s/he does not know what they will find at surgery. A needle biopsy may or may not be done first. If a needle biopsy is being done, it is based on the palpable finding (feeling the lump) this would be done by the surgeon, not the radiologist.