When a lump is found in a breast or an abnormality is identified on a mammogram a decision must be made whether to biopsy it or not and how to biopsy it. Choices range from an open surgical procedure to new minimally invasive techniques. Amoung breast cancer experts there is a consensus that nearly all abdnormalities should be biopsied with a needle prior to surgery. The use of ultrasound, stereotactic tables, and various biopsy devices have revolutionized the way these abnormalities are approached. A surgeon that is experienced in all types of biopsies is the best person to help you make these decisions. It is unusual to simply remove the abnormality without ultrasound evaluation or needle biopsy. If it is going to be removed, you and your surgeon should have a very good idea whether it is a cancer or not before you go to the operating room. While the thought of having a breast biopsy might be frightening, the results can provide reassuring peace of mind. Remember, the vast majority of breast biopsies do not turn out to be breast cancer. And a biopsy is currently the only way to achieve an accurate breast cancer diagnosis.
There are various breast biopsy options to consider. Be sure to understand your biopsy options and talk with your surgeon to determine the procedure that is best for you.
Image Guidance During Biopsy Procedures
Image guidance with ultra-sound and stereotactic techniques have improved the methods of breast biopsy. By accurately pinpointing and mapping the area to be biopsied, your surgeon can gather tissue samples (or cellular material) without making large incisions.
There are two methods for producing images in minimally invasive breast biopsies: Stereotactic and ultrasound imaging. Stereotactic [STARE-ee-o-TAK-tik] biopsies use mammography (x-rays) to locate breast abnormalities, while ultrasound biopsies use high-frequency sound waves to create breast tissue images.
Minimally invasive breast biopsies using ultrasound imaging are performed on patients usually in a reclined position. Using a hand-held transducer, a doctor will move the device back and forth across the breast to generate clear images of the abnormal breast tissue. While viewing the images on a computer monitor, the doctor will guide a small probe into the breast to retrieve sample tissue specimens. Biopsy with ultrasound guidance is the easiest, most comfortable and cheapest way to biopsy breast abnormalities.
If the abnormality was found with mammography and is not visible with ultraound, then a stereotactic biopsy will be used. The patient lies face down on a special table with her breast protruding through a hole in the table’s surface. The breast is lightly compressed to immobilize it throughout the biopsy procedure. The table is connected to a computer that produces detailed x-ray images of the abnormality to be biopsied. Using these images, the doctor guides a special sampling device (for example, a Mammotome® biopsy probe) to collect tissue specimens.
Excisional Biopsy — This is a traditional surgical biopsy. It is done in an operating room as an outpatient, usually under local anesthetic with some sedation. The patient usually has no awareness of the procedure. Sometimes a general anesthetic will be used.
Wire localization biopsy — If an abnormality is not palpable, the surgeon will need some guidance to find it. Most of these lesions are biopsied with a needle in the office to establish a diagnosis. If it still needs to be removed there are several alternatives to locating the abnormality. Before the operation the radiologist will use the mammogram machine to place a needle in the breast in the vicinity of the lesion in question. Once the needle is in the right place, a small “hooked wire” will be placed through the needle and the needle is removed. The patient is taken to the operating room for an open surgical biopsy. An x-ray of the specimen is usually taken to confirm the right area was removed. Sometimes the wire is placed in the breast using a stereotactic table. Another way to localize these lesions is to use the ultrasound (with a sterile cover) in the operating room. This avoids the preoperative placement, saves time and is easier for the patient because she is sedated.
Cyst Aspiration — A cyst is a lump that is full of fluid. They are almost always benign; however, if a cyst is large and tender, removing the fluid (aspirating the fluid) will bring relief and likely make the cyst go away. This is done with a small needle (about the same size as the needles used to draw blood), and the skin is anesthitized with some local anesthetic. Aspirating a cyst with ultrasound guidance ensures that all of the fluid is removed which will decrease the chances of the cyst comming back. The fluid is usually not sent for analysis unless it is bloody or otherwise suspicious.
Fine Needle Aspirations — The small needle used to aspirate cysts can also be used to get some cells out of a lesion for cytological analysis. This can be helpful in confirming something is benign but is usually not a definitive test. This test is not as reliable as the biopsies described below.
Core Needle — This needle is about the same size as a #2 pencil lead. It is used with a spring activated device and will take a “core” of tissue for the pathologist to examine. After the skin is injected with local anesthetic a small incision is made in the skin and several samples are usually taken. The small incision is covered with a band-aid. The Cassi devise is a excellent tool in biopsying small nodules with a great amount of accuracy.
Vacuum Assisted Core Needle (Mammotome® System) — This is a special device that removes a larger sample of breast tissue to increase the accuracy of the biopsy It can actually remove benign lumps up to about an inch in diameter. This procedure is done in the office with a local anesthetic. A small probe is inserted into the breast through an incision about the size of a match head. A vacuum is used to gently draw, cut and collect tissue into the probe’s hollow chamber. This biopsy technique enables several samples to be acquired resulting in a highly accurate breast cancer diagnosis. Since multiple tissue samples are obtained without removing and reinserting the probe, there is less internal scarring which minimizes interference with future monitoring and diagnosis of breast abnormalities. It is always used with ultrasound or stereotactic guidance. Following a breast biopsy using the Mammotome® System, the patient is typically sent home with a small adhesive bandage to cover the incision. The breast biopsy can be completed in less than one hour and is performed in the surgeon’s office without general anesthesia or stitches.
It is important that you see a doctor that is familiar with all of the various approaches to breast biopsies. A surgeon that performs all of these procedures is best qualified to make the appropriate decision for any particular breast problem.