Breast biopsy

Last updated
Surgical Breast Biopsy
Surgical breast biopsy.jpg
Surgeon doing a surgical breast biopsy
ICD-9-CM 85.11-85.12

A breast biopsy is usually done after a suspicious lesion is discovered on either mammography or ultrasound to get tissue for pathological diagnosis. [1] Several methods for a breast biopsy now exist. [2] The most appropriate method of biopsy for a patient depends upon a variety of factors, including the size, location, appearance and characteristics of the abnormality. [3] The different types of breast biopsies include fine-needle aspiration (FNA), vacuum-assisted biopsy, core needle biopsy, and surgical excision biopsy. [3] [4] [5] Breast biopsies can be done utilizing ultrasound, MRI or a stereotactic biopsy imaging guidance. [2] [5] [4] [6] Vacuum assisted biopsies are typically done using stereotactic techniques when the suspicious lesion can only be seen on mammography. [5] On average, 5–10 biopsies of a suspicious breast lesion will lead to the diagnosis of one case of breast cancer. [7] Needle biopsies have largely replaced open surgical biopsies in the initial assessment of imaging as well as palpable abnormalities in the breast. [8]

Contents

Indications

There are many reasons why a doctor may order a breast biopsy. [7] Typical indications include:

Fine-needle aspiration

Fine-needle aspiration Needle biopsy.jpg
Fine-needle aspiration

Fine-needle aspiration (FNA) is a percutaneous ("through the skin") procedure that uses a fine needle and a syringe to sample fluid from a breast cyst or remove clusters of cells from a solid mass. [6] It is mainly used to differentiate between a cyst and a mass. [6] If the aspirated contents are not cyst-like, then a tissue sample must be taken to better evaluate the mass. [6] Fine-needle aspiration is one of the most commonly used initial diagnostic tools for suspicious lesions. [12] The doctor will typically use a 22 or 27 gauge needle to aspirate out free fluid and cells. [12] It can be done in an outpatient setting and is associated with minimal pain. [12] However, in up to 30% of cases, pathological slides from fine-needle aspiration of breast lesions may be inconclusive, necessitating the need for further testing. [12] FNA can be done to aspirate the contents of a cyst, which may relieve any pain that the cyst caused, or can be used to aspirate a suspicious lesion in conjunction with cytology (cellular analysis). [13] If aspirating the contents of a cyst, the aspirate is usually not sent for cytology unless it is bloody. [13] If the cyst is not detectable by touch, it may be located using ultrasound, MRI, or stereotactic mammography. [13] Recovery time from an outpatient FNA is minimal. [13]

Core needle biopsy

Core needle biopsy (CNB) is another percutaneous ("through the skin") method of breast biopsy that became more popular than FNA in the 1990s due to the larger sample of tissue CNB provides. [14] This method is usually done under ultrasound guidance and involves using two needles, one inner "puncture" needle that is inserted into the mass, and a wider gauge needle with an open "gap" or "trough" on one side that allows for tissue to enter. [11] A spring-loaded sheath then is triggered by the technician that covers the trough in the needle to allow sample tissue to be separated and removed for analysis. [11] Typically four tissue samples are removed to minimize sample error. To prevent the need to pierce the breast repeatedly, a coaxial needle is left in place on top of the mass as a guide. [11] CNB has a higher sensitivity for cancer than FNA, has lower false negatives, and has proven more successful in finding rare breast diseases like lobular carcinoma. However, this method still has relatively high rates of false negatives compared to surgical or vacuum-assisted methods due to the overall low volume of tissue removed. [14] [11] Also, because breast tissue can be difficult to target on ultrasound, as many as 5–10% of suspicious lesions are missed by the needle and may result in a high rate of false negatives, or the need for additional biopsies. [14]

Stereotactic biopsy

Stereotactic biopsy is done with the help of a specialized device, which provides mammographic guidance. For a stereotactic biopsy, morbid obesity is a relative contraindication due to weight limitations of the devices. Pregnancy and breast compression size may also be contraindications depending on the modality being used. [15]

Vacuum-assisted breast biopsy

Vacuum-assisted breast biopsy (VABB) is a more recent version of core needle biopsy using a vacuum technique to assist the collection of the tissue sample. Similarly to core needle biopsy, the needle has a lateral ("from the side") opening and can be rotated, allowing multiple samples to be collected through a single skin incision. This method has become more popular than FNA, CNB, and surgical biopsies due to the benefits of low invasiveness while still obtaining a larger tissue sample. [14] Taking more tissue helps reduce sampling error since breast lesions are often heterogeneous (cancer cells are spread unevenly) and therefore cancer can be missed if not enough tissue is taken. VABB can be guided by stereotactic (most popular), ultrasound, and MRI, and can yield as much as 2g of tissue sample. [14] The vacuum-assisted biopsy category also includes automated rotational core devices. [16]

Direct and frontal biopsy

Recent innovations in tissue acquisition for the human breast have led to the development of unique direct frontal systems. Efficacy is considered optimal if the diagnosis by transcutaneous biopsy is identical to the surgical specimen in case of malignancy or in line with clinical follow-up when benign.[ citation needed ]

The direct and frontal biopsy systems can even be considered relatively painless. The quality of the sample is sufficient for research on molecular biology. [17] [18] [19]

Excisional (surgical) biopsy

Surgical breast biopsy specimen that has been inked on all sides to aid a pathologist in evaluating tissue margins under the microscope. Inked Lumpectomy Specimen (6464023675).jpg
Surgical breast biopsy specimen that has been inked on all sides to aid a pathologist in evaluating tissue margins under the microscope.

Excisional biopsy involves surgically removing the suspicious area of the breast to examine it under the microscope for diagnosis. One method is wire-guided (or wire-localized) excisional biopsy, where a wire is inserted into the breast and repeatedly imaged using breast ultrasound or mammography until the technician sees that the tip is located in the suspicious area. The suspicious area is then removed entirely in one block by the surgeon with the help of the wire. [10] [20] When the tissue is removed, it is processed by a pathologist, who describes the tissue as it appears by eye and inks the sides to help orient the tissue under the microscope after it is sliced. [10] Each color corresponds to a direction, such as superior, inferior, medial, lateral, anterior, and posterior (these correspond to top, bottom, outside, inside, front, and back). [10] When the tissue is then looked at under the microscope, the margins can then be evaluated to see if they are free of cancer cells, or if the surgeon needs to go back and remove more tissue from that area. [10] Titanium surgical clips are often left behind by surgeons to help future physicians locate the site and monitor for future disease or target the area with radiation if needed. [10] Percutaneous ("through the skin") biopsy methods have become more favored over surgical biopsies due to the high rate of benign findings (80%) and the reduction of adverse effects such as scarring. [11]

Adverse effects

Radiographic marker in a lumpectomy specimen Radiographic Marker in Lumpectomy Specimen (3595823780).jpg
Radiographic marker in a lumpectomy specimen

Adverse effects of breast biopsies tend to vary depending on what type of biopsy is performed. The more invasive, such as surgery, tend to have more severe types of adverse incidents, whereas less invasive such as FNA or CNB tend to have less severe. For vacuum-assisted biopsies, some complications of the procedure can include bleeding, post-operative pain, and hematoma formation. [14] However, most can be avoided with proper application of pressure and rest. [14] Some examples of adverse effects of core needle biopsies can include rare biopsy risks like infection, abscess formation, fistula formation, migration of any markers placed in the breast, and potential seeding of the tumor (causing displacement of cancer cells due to the procedure that can start new tumors elsewhere). [1] [21] Another potential adverse effect occurs when taking a biopsy of an area of microcalcification. If the entire area of microcalcification is removed, it is then very difficult to find the suspicious area in the future for treatment. A marker is placed in the suspicious area to help localize the proper area for possible removal at a later date; if this is removed during biopsy, it can be difficult to make sure that the correct area was excised in surgery. [21] Bleeding into the site of the suspicious lesion caused by the biopsy procedure can appear to look like a complex cyst on ultrasound, which could lead to additional unnecessary management. [13] The false negative rate of the results of a breast biopsy is approximately 1%. [13]

Related Research Articles

<span class="mw-page-title-main">Cytopathology</span> A branch of pathology that studies and diagnoses diseases on the cellular level

Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1928. Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues. Cytopathology is frequently, less precisely, called "cytology", which means "the study of cells".

<span class="mw-page-title-main">Biopsy</span> Medical test involving extraction of sample cells or tissues for examination

A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a disease. The tissue is then fixed, dehydrated, embedded, sectioned, stained and mounted before it is generally examined under a microscope by a pathologist; it may also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. An incisional biopsy or core biopsy samples a portion of the abnormal tissue without attempting to remove the entire lesion or tumor. When a sample of tissue or fluid is removed with a needle in such a way that cells are removed without preserving the histological architecture of the tissue cells, the procedure is called a needle aspiration biopsy. Biopsies are most commonly performed for insight into possible cancerous or inflammatory conditions.

<span class="mw-page-title-main">Fibroadenoma</span> Medical condition

Fibroadenomas are benign breast tumours characterized by an admixture of stromal and epithelial tissue. Breasts are made of lobules and ducts. These are surrounded by glandular, fibrous and fatty tissues. Fibroadenomas develop from the lobules. The glandular tissue and ducts grow over the lobule to form a solid lump.

<span class="mw-page-title-main">Fine-needle aspiration</span> Diagnostic medical procedure

Fine-needle aspiration (FNA) is a diagnostic procedure used to investigate lumps or masses. In this technique, a thin, hollow needle is inserted into the mass for sampling of cells that, after being stained, are examined under a microscope (biopsy). The sampling and biopsy considered together are called fine-needle aspiration biopsy (FNAB) or fine-needle aspiration cytology (FNAC). Fine-needle aspiration biopsies are very safe minor surgical procedures. Often, a major surgical biopsy can be avoided by performing a needle aspiration biopsy instead, eliminating the need for hospitalization. In 1981, the first fine-needle aspiration biopsy in the United States was done at Maimonides Medical Center. Today, this procedure is widely used in the diagnosis of cancer and inflammatory conditions. Fine needle aspiration is generally considered a safe procedure. Complications are infrequent.

<span class="mw-page-title-main">Pleomorphic adenoma</span> Medical condition

Pleomorphic adenoma is a common benign salivary gland neoplasm characterised by neoplastic proliferation of epithelial (ductal) cells along with myoepithelial components, having a malignant potentiality. It is the most common type of salivary gland tumor and the most common tumor of the parotid gland. It derives its name from the architectural Pleomorphism seen by light microscopy. It is also known as "Mixed tumor, salivary gland type", which refers to its dual origin from epithelial and myoepithelial elements as opposed to its pleomorphic appearance.

<span class="mw-page-title-main">Ductal carcinoma in situ</span> Medical condition

Ductal carcinoma in situ (DCIS), also known as intraductal carcinoma, is a pre-cancerous or non-invasive cancerous lesion of the breast. DCIS is classified as Stage 0. It rarely produces symptoms or a breast lump one can feel, typically being detected through screening mammography. It has been diagnosed in a significant percentage of men.

<span class="mw-page-title-main">Fibrocystic breast changes</span> Medical condition

Fibrocystic breast changes is a condition of the breasts where there may be pain, breast cysts, and breast masses. The breasts may be described as "lumpy" or "doughy". Symptoms may worsen during certain parts of the menstrual cycle due to hormonal stimulation. These are normal breast changes, not associated with cancer.

<span class="mw-page-title-main">Surgical pathology</span> Area of practice for anatomical pathologists

Surgical pathology is the most significant and time-consuming area of practice for most anatomical pathologists. Surgical pathology involves gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and non-surgeons such as general internists, medical subspecialists, dermatologists, and interventional radiologists.

<span class="mw-page-title-main">Breast cyst</span> Medical condition

A breast cyst is a cyst, a fluid-filled sac, within the breast. One breast can have one or more cysts. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but sometimes a breast cyst feels firm.

<span class="mw-page-title-main">Thyroid nodule</span> Medical condition

Thyroid nodules are nodules which commonly arise within an otherwise normal thyroid gland. They may be hyperplastic or tumorous, but only a small percentage of thyroid tumors are malignant. Small, asymptomatic nodules are common, and often go unnoticed. Nodules that grow larger or produce symptoms may eventually need medical care. A goitre may have one nodule – uninodular, multiple nodules – multinodular, or be diffuse.

Stereotactic biopsy, also known as stereotactic core biopsy, is a biopsy procedure that uses a computer and imaging performed in at least two planes to localize a target lesion in three-dimensional space and guide the removal of tissue for examination by a pathologist under a microscope. Stereotactic core biopsy makes use of the underlying principle of parallax to determine the depth or "Z-dimension" of the target lesion.

<span class="mw-page-title-main">Mammotome</span>

Mammotome is a Cincinnati, OH based company who pioneered a vacuum-assisted breast biopsy (VAC) device that uses image guidance such as x-ray, ultrasound and/or MRI to perform breast biopsies. A biopsy using a Mammotome® device can be done on an outpatient basis with a local anesthetic. The Mammotome brand is sold in over 45 different countries throughout the world.

<span class="mw-page-title-main">Fat necrosis</span> Medical condition

Fat necrosis is a form of necrosis that is caused by the action of lipases on adipocytes.

The term nonpuerperal mastitis describes inflammatory lesions of the breast (mastitis) that occur unrelated to pregnancy and breastfeeding.

<span class="mw-page-title-main">Atypical ductal hyperplasia</span> Medical condition

Atypical ductal hyperplasia (ADH) is the term used for a benign lesion of the breast that indicates an increased risk of breast cancer.

<span class="mw-page-title-main">Breast mass</span> Localized swellings that feel different from the surrounding tissue

A breast mass, also known as a breast lump, is a localized swelling that feels different from the surrounding tissue. Breast pain, nipple discharge, or skin changes may be present. Concerning findings include masses that are hard, do not move easily, are of an irregular shape, or are firmly attached to surrounding tissue.

<span class="mw-page-title-main">Breast ultrasound</span> Type of medical imaging

Breast ultrasound is a medical imaging technique that uses medical ultrasonography to perform imaging of the breast. It can be performed for either diagnostic or screening purposes and can be used with or without a mammogram. In particular, breast ultrasound may be useful for younger women who have denser fibrous breast tissue that may make mammograms more challenging to interpret.

<span class="mw-page-title-main">Triple test score</span>

The triple test score is a diagnostic tool for examining potentially cancerous breasts. Diagnostic accuracy of the triple test score is nearly 100%. Scoring includes using the procedures of physical examination, mammography and needle biopsy. If the results of a triple test score are greater than five, an excisional biopsy is indicated.

Breast hematoma is a collection of blood within the breast. It arises from internal bleeding (hemorrhage) and may arise due to trauma or due to a non-traumatic cause.

<span class="mw-page-title-main">Breast imaging</span>

In medicine, breast imaging is a sub-speciality of diagnostic radiology that involves imaging of the breasts for screening or diagnostic purposes. There are various methods of breast imaging using a variety of technologies as described in detail below. Traditional screening and diagnostic mammography uses x-ray technology and has been the mainstay of breast imaging for many decades. Breast tomosynthesis is a relatively new digital x-ray mammography technique that produces multiple image slices of the breast similar to, but distinct from, computed tomography (CT). Xeromammography and galactography are somewhat outdated technologies that also use x-ray technology and are now used infrequently in the detection of breast cancer. Breast ultrasound is another technology employed in diagnosis and screening that can help differentiate between fluid filled and solid lesions, an important factor to determine if a lesion may be cancerous. Breast MRI is a technology typically reserved for high-risk patients and patients recently diagnosed with breast cancer. Lastly, scintimammography is used in a subgroup of patients who have abnormal mammograms or whose screening is not reliable on the basis of using traditional mammography or ultrasound.

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