Breast Biopsy Options

You will be offered several options for diagnosis and treatment of your breast problem. The options will be given to you, recommendations will be made, and you will be able to decide what works best for you.

BIOPSY: LEARNING IF YOU HAVE BREAST CANCER

If you have noticed a lump or other change in your breast, your doctor may recommend several tests to determine if you indeed have cancer. After taking your medical history and performing a manual breast exam, your doctor may recommend a breast x-ray or mammogram, ultrasound, and/or MRI. You may be asked to have a combination of these tests. If the lump is suspected to be a cyst, your doctor may use a needle to drain fluid from the lump.

Another test is a biopsy where tissue is removed and a pathologist examines it under a microscope. The mass or a portion of it is removed under local or monitored anesthesia. Biopsy is the only certain way to diagnose breast cancer. Minimally invasive core biopsies using mammography and ultrasound to guide the procedure have become the standard of care when it is technically feasible. Complete surgical excision biopsy may be recommended if the mass is located in a part of the breast that makes this the best option for diagnosis.

During the biopsy procedure, the surgeon removes the suspicious tissue to see if it is benign or malignant. If it is malignant, the pathologist will try to identify the type of cancer cells present, how fast they reproduce, if the blood vessels or lymph systems contain cancer cells, and if the cancer’s growth is affected by hormones. This information allows your doctor to determine the best treatment for you.

There are two ways that a pathologist prepares the tissue for examination-a “frozen section," which is a quick procedure that takes about 30 minutes, and a “permanent section,” which takes two to three days.

The frozen section is a quick way of determining whether or not cancer is present in the tissue. The permanent section is the most accurate method.


MINIMALLY INVASIVE BREAST BIOPSY

Stereotactic Breast Biopsy-With this type of biopsy, the mammogram is used as our guide to obtain the specific tissue that we need to sample.

You are placed face down on the table and your breast hangs through a hole in the table. The breast is then imaged with a low dose mammogram to find the density or area of calcifications. Once the area is identified, the computer helps to determine the appropriate placement of the device. Once images are confirmed, the breast is cleansed and anesthetized with local anesthesia. After a tiny nick is made in the skin, the device is positioned and checked. The area is further infiltrated with Lidocaine to numb or deaden the area. The samples are then taken and an x-ray confirms the presence of the calcifications in the specimens. At the completion of the procedure, a radiologic marker is placed to mark the area for further reference. The marker may be made of titanium or surgical steel. Don’t worry; they will not set off the metal detectors in the airport!


This marker allows us to know where to return to if further surgery is needed, and it also allows the radiologist in the future know that you did indeed have a biopsy of that area. When the procedure is completed, the technologist will initially hold pressure on the area and then apply Steri-strips or surgical glue. An outer dressing is placed. You may have a regular mammogram immediately after the procedure if one is necessary to confirm that the appropriate area has been biopsied.

Risks
•Bleeding, hematoma
•Infection
•Failure to sample the appropriate area
•Bruising
•Neck stiffness (resulting from the positioning on the table)
•Repeat procedure if unsuccessful

Benefits
•Minimally invasive
•Less disruption to normal tissue
•Specifically targets the area in question
•More rapid pathology evaluation
•No general anesthesia
•Less time away from your work or play

Vacuum-Assisted Core Biopsy-Biopsy with Ultrasound Guidance-This procedure is performed when there is either an ultrasound abnormality or a palpable mass in the breast. The patient is placed in the supine position and her arm is usually over her head.

Once the breast is scanned with the ultrasound machine, the area for biopsy is marked with a surgical marker. The breast is then cleansed with Betadine and anesthetized with Lidocaine. The incision is made as a tiny nick in the skin. A larger needle is then used to assure the area is completely numb. Once the Lidocaine is allowed to work, the device is inserted under ultrasound guidance.

Once position is checked, the area is sampled. If all image evidence of the lesion is to be removed, the procedure is continued until the ultrasound image of the density confirms the removal. A tiny marker is then placed for future reference. Pressure is held over the biopsy cavity and then Steri-strips and sterile dressings are placed. A mammogram may be performed if confirmation of a mammographic lesion is necessary.

Risks
•Bleeding
•Infection
•Skin dimpling
•Sampling Error

Benefits
•Can be performed in the doctor’s office
•Outpatient
•Local anesthesia
•Minimal disruption to normal tissue
•More rapid pathology reporting

Core Needle Biopsy-A biopsy performed in the doctor’s office to make a diagnosis of a breast problem. When the patient and the doctor feel a lesion, a core biopsy can be used to confirm a diagnosis and/or to rule out a cancer. The procedure involves the cleansing and numbing of the skin.

A small nick is then made in the skin and the core needle device is repeatedly placed in the breast, fired and removed, until adequate samples are obtained. With this biopsy technique the area is not removed, just sampled. No sutures are needed, just Steri-strips to approximate the skin.

Fine Needle Aspiration-A procedure that is performed to sample cells from a solid lesion or to confirm that a mass is a fluid filled cyst. A skinny needle is inserted into the breast without anesthesia. This may be done with or without ultrasound guidance.

If fluid is obtained, it may be discarded or tested based upon its consistency. Further biopsies may be required if the mass is solid.

Open Surgical Biopsy-A procedure performed in the operating room that will remove a palpable mass. It is always an option when you can feel the lesion. It is at times the recommended procedure if the mass is near the nipple or very close to the surface of the skin.

Risks
•Bleeding
•Infection
•Anesthesia
•Defect in the breast
•Scar formation

Needle Localization Biopsy-An open biopsy that uses the placement of a needle to guide the surgeon to the area of interest. It is placed under mammographic guidance or ultrasound guidance. It may be used as a primary procedure or as a follow-up to a stereotactic or vacuum-assisted core biopsy.

Risks
•Same as open biopsy
•Inability to remove the lesion, clip or calcifications


THE FROZEN SECTION
The frozen section is performed while the patient is in the operating room. A frozen section is requested and performed if it will change the intraoperative management of your breast disease.

Many lesions, which are small or are found by needle localization, are often best served by the permanent section. The purpose is to obtain a correct final answer and avoid a quick, potentially inaccurate, answer.


THE PERMANENT SECTION
The permanent section takes longer than a frozen section-usually two or three days. In this permanent section process, the tissue is treated by a series of chemical solutions that give a high quality slide. The advantage of this process is that it is more accurate and allows the pathologist to make a more correct diagnosis. Permanent sections are always done, even if the frozen section was previously performed.

If your lump is cancerous, estrogen and progesterone receptor assay tests will be performed as well as testing for Her-2-neu expression. These tests will determine whether treatment with anti-estrogen agents may benefit you. The cancer is also graded on a microscopic level (Grade I, II, III) to give your physicians an estimate of the aggressiveness of the tumor.