Breast Biopsies

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What is a breast biopsy?

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A breast biopsy is a procedure in which part or all of a breast abnormality is removed. The can be done with specially-designed needles or with surgery. The specimen is then prepared and examined under a microscope by a pathologist to tell if it is benign or cancer. The pathology report will indicate the diagnosis (specifically what type of cancer or benign finding it is) and its characteristics. A biopsy is often the only way to know for sure if cancer is present.

 

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Why are breast biopsies done?

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Biopsies are performed to determine if a breast abnormality is benign or if it is cancer. They are used to evaluate abnormalities on breast examination, such as breast lumps, nipple discharges, nipple lesions, skin changes or enlarged lymph nodes in the underarm or near the collar bone. Biopsies are also performed for abnormalities on mammogram, breast ultrasound or breast MRI. Not all breast abnormalities require a biopsy to figure out what they are. For some abnormalities a breast exam, ultrasound or mammogram is all it takes to be sure they are benign.  Biopsies are done if the abnormality meets certain criteria. In the United States, biopsy criteria are set so about 25% of breast biopsies show cancer. This minimizes the possibility of missing or delaying a breast cancer diagnosis. If a biopsy is the only way to tell if a breast abnormality is a cancer, then a benign biopsy is not an “unnecessary procedure” or a “false positive” result. It can be helpful and reassuring to find out that a breast lesion is definitely benign. Some benign findings are associated with a higher chance of getting breast cancer in the future, and this is important to know because women with these findings may consider more intensive breast cancer screening or measures to reduce their breast cancer risk.

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What types of breast biopsies are there?

 

There are several different types of biopsies, each with its own advantages and disadvantages. There are needle biopsies and surgical breast biopsy techniques. Most breast abnormalities can be accurately biopsied with less invasive needle biopsy techniques, but the best form of biopsy varies based on the specific circumstances. Breast surgeons are the only specialists who perform both needle and surgical biopsies, and so are uniquely able to guide patients about which form of biopsy is best for a particular situation.

 

Needle Biopsies

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Fine needle aspiration biopsy

This office procedure is the least invasive type of biopsy and does not cause a scar. Local anesthesia is used to numb the area. A thin needle is inserted into a breast mass or other abnormality, usually under ultrasound guidance, and suction is applied to an attached syringe to remove fluid or cells. This can be used to diagnose and treat breast cysts, or to obtain a sample from a solid mass to make a diagnosis.

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Core needle biopsy

All core needle biopsies use similar biopsy instruments to obtain tissue samples from breast abnormalities.  A specialized needle is used to remove slivers of the abnormality.  The intention is to sample the abnormality to make a diagnosis, not necessarily to remove the whole lesion. They can be guided by palpation or by ultrasound, stereotactic (mammographic) or MRI guidance.

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Ultrasound-guided core needle biopsy

This type of biopsy can be used if a breast abnormality is visible on ultrasound. This procedure is minimally invasive, and is done with a topical anesthetic cream and local anesthesia. For patients who are “needle-phobic”, an oral sedative can be used to make the experience more relaxed.  A small nick is made in the skin, and a specially-designed needle biopsy instrument is inserted into the abnormality while the doctor watches on the ultrasound screen to be sure it is in the right place. Then multiple biopsy specimens are obtained.  This increases the accuracy of the procedure. An clip is placed to mark the biopsy site for future reference; the clip will not cause pain or any other symptoms, does not interfere with MRI, and will not cause metal detectors to alarm. With non-vacuum-assisted devices, the instrument is taken in and out of the breast to remove each piece of tissue. By using vacuum-assisted needle biopsy devices, multiple specimens can be obtained while the instrument is in the breast.  We use vacuum-assisted devices for almost all core needle biopsies because they remove better tissue samples and are more comfortable since the instrument is only inserted one time.

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Stereotactic biopsy

This is a minimally invasive core needle biopsy which is used for abnormalities which are visible on mammogram, especially if they cannot be seen on ultrasound, such as clustered calcium deposits. It is done under local anesthesia or topical anesthetic cream or spray, depending on the preference of the radiologist.  A special computer-assisted mammography unit is used. The patient lies on her stomach and her breast fits through an opening in the procedure table.  A mammogram is done, and the computer calculates where the abnormality is in 3 dimensions, and guides the biopsy needle which is inserted through a small skin nick. Multiple samples are taken of the area of concern. The specimens may be x-rayed after they are removed to be sure adequate samples have been obtained. A marking clip is placed at the biopsy site. We arrange stereotactic biopsies for our patients at the most experienced breast imaging radiology facilities in the area.

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Affirm (3-D) - guided core needle biopsy

This is a minimally invasive core needle biopsy which is used for abnormalities which are only visible or best seen on tomosynthesis (3-D) mammogram images. It is a form of stereotactic biopsy, but tomosynthesis (3_D) mammographic guidance is used. It is done under local anesthesia or topical anesthetic cream or spray, depending on the preference of the radiologist.  A special computer-assisted 3-D mammography unit is used. A mammogram is done, and the computer calculates where the abnormality is in 3 dimensions, and guides the biopsy needle which is inserted through a small skin nick. Multiple samples are taken of the area of concern. The specimens may be x-rayed after they are removed to be sure adequate samples have been obtained. A marking clip is placed at the biopsy site. We arrange Affirm-guided biopsies for our patients at the most experienced breast imaging radiology facilities in the area.

 

MRI-guided core needle biopsy

MRI guided biopsies are used to evaluate breast abnormalities which can only be seen on breast MRI. The core biopsy sampling technique is the same as it is for ultrasound-guided or stereotactic core needle biopsies, but instead of identifying the abnormality and guiding the biopsy procedure with an ultrasound or mammogram, breast MRI is used. We arrange MRI-guided core needle biopsies at experienced radiology facilities.
 

Surgical Biopsies

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Excisional breast biopsy

This is a surgical procedure which is performed in the operating room, usually with local anesthesia and intravenous sedation, so that the woman is in a “twilight sleep” and not aware during the surgery.  An incision is made in the breast, placing it in the best cosmetic way, and the abnormality is completely removed (excised) surgically. The incision is closed using plastic surgical techniques with dissolvable sutures under the skin to give the best possible cosmetic result.

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Breast biopsy with wire localization

This is a type of excisional biopsy which is used for abnormalities on breast imaging (mammogram, ultrasound or MRI) which cannot be felt, often because a needle biopsy was inconclusive.  To be sure the right area is removed, a wire is inserted through the skin into the breast through or next to the targeted lesion under image guidance. The image guidance could be with ultrasound, mammography or breast MRI.  The localizing wire can be placed under ultrasound guidance in the operating room by the breast surgeon while the patient is under anesthesia if the abnormality can be seen on ultrasound, if an ultrasound-visible clip was placed in the lesion at the time of a stereotactic or MRI-guided needle biopsy, or if an ultrasound visible clip was placed within the lesion prior to surgery.  This is clearly the most comfortable way to have the localizing wire placed, since the patient is under anesthesia and unaware during the placement.  It also means the wire has been placed in the best possible way to guide the surgical procedure, and only the possibility that the wire wouldn’t become dislodged or displaced with movement from breast imaging to the operating room to the operating table.

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Otherwise, the localizing wire would be placed by a radiologist shortly before the surgery under stereotactic or MRI- guidance, with local anesthesia. Our surgeons order topical anesthesia and an oral sedative prior to the wire localizations done in the radiology department to increase patient comfort since patients are awake for these localizations.

In the operating room under anesthesia, an incision is made in the breast, placing it in the best cosmetic way, and the tissue around the localizing wire is removed. An ultrasound or x-ray of the specimen is typically done to show that the abnormality has been successfully removed and is in the specimen. The incision is closed using plastic surgical techniques with dissolvable sutures under the skin to give the best possible cosmetic result.

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Duct excision

A duct excision is a special type of excisional biopsy done to evaluate suspicious nipple discharges. The duct excision is done in the operating room under intravenous sedation and local anesthesia. A tiny catheter is used to inject dye into the duct opening on the surface of the nipple from which the discharge flows. A small incision is made along the edge of the areola, the dark skin around the nipple, and the blue-stained ducts (which are the source of the discharge) are surgically removed. The incision is closed using plastic surgical techniques with dissolvable sutures under the skin to give the best possible cosmetic result.  The scar is hidden in the natural line at the edge of the areola.

 

 

What to expect during and after a breast biopsy

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With a needle biopsy, the topical cream starts to numb the area prior to the procedure. You will feel a small stick and mild burning with the injection of the local anesthesia. After that, you will feel movement and pressure, but you shouldn't feel any pain. If you do, more local anesthesia can be used. A bandage will be placed over the incision and Arnica gel will be applied to the breast to reduce bruising. After the procedure, you may have soreness or discomfort. There usually is some bruising after a needle biopsy. An ice pack can relieve the discomfort and reduce swelling and bruising. You will be able to drive yourself to and from the appointment and work by the next day.

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With a surgical biopsy, you will be under sedation and unaware during the procedure. A long-acting local anesthetic will be used at the end of the surgery so you will wake up feeling comfortable. An ice pack will help reduce discomfort, swelling and bruising. You probably won't need more than tylenol, but we will give you a prescription for pain medication just in case. You should not drive or make important decisions for 24 hours after receiving sedation.

Advantages and disadvantages of needle biopsies versus surgical biopsies.

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Needle biopsies are less invasive, remove less tissue and leave a smaller scar than surgical biopsies. There is less time off of work. Both core needle and surgical biopsies are highly accurate. There is a 1-3% chance of a false negative result (getting a benign result when there actually is a cancer) with an image-guided core needle biopsy. There is a 0-1% chance of a false negative result with a surgical biopsy. There is a possibility of getting an inconclusive result with a needle biopsy which would require a surgical biopsy to obtain a definitive diagnosis. Inconclusive findings on needle biopsy include atypical hyperplasia, papillary findings or radial scar because there is a 15-20% risk of an associated cancer, so a surgical biopsy is necessary to fully evaluate the abnormality. There is a 3% possibility of missing a nonpalpable lesion on surgical breast biopsy with wire localization. Both needle and surgical biopsies have a small risk for bleeding, infection or poor healing.  Most breast abnormalities are amenable to image-guided needle biopsies.

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Results

A pathology report will be made based on the microscopic evaluation of the biopsied tissue. The diagnosis and any additional recommendations will be explained in detail by your surgeon at your appointment 4 business days after the biopsy. If pathology results are available sooner, your breast surgeon will contact you with the results, with the plan that the results will be discussed in more detail at your post-biopsy appointment.

If a core needle biopsy is benign, follow consists of a breast exam and imaging at 6 and 12 months after the biopsy. If the biopsied lesion changes in a suspicious way, a surgical biopsy would be performed.  If a surgical biopsy is benign, there is a final post-operative appointment 2 months after the surgery. Breast imaging may be repeated at that time to document removal of the lesion and to establish a new baseline. Some benign findings, such as atypical ductal or lobular hyperplasia or LCIS, are associated with an increased risk for breast cancer. Computer-based breast cancer risk assessment, a plan for monitoring and risk-reduction strategies will be discussed at the post-biopsy appointment. If the pathology reveals cancer, your surgeon will discuss a comprehensive diagnostic and treatment plan, and coordinate multidisciplinary care with a team of specialists.