Breast Biopsy

Lumps and pain in the breast are common and can have numerous causes.

• A breast biopsy procedure is usually done to determine whether growth in the breast is cancerous or benign.
• A lump or other sign of breast cancer in a man or woman may warrant a breast biopsy.
• A breast biopsy can be done with a needle or by a surgical procedure.
• Nonsurgical biopsies tend to be less stressful and minimize the risk of complications.
• Nonsurgical biopsies are not always as reliable as surgical biopsies in producing a conclusive diagnosis.
• The breast biopsy may be accompanied by imaging (such as X-rays, MRI, or ultrasound) guidance.
• A fibroadenoma is the most common type of benign (noncancerous) breast tumor and is found in young women.
• Except for a minor sting from the injected anesthesia, patients usually feel no pain before or during a procedure.

A breast biopsy is a procedure in which part or all of a suspicious area in the breast is removed and examined, usually for the presence of breast cancer. The growth sample is suctioned out through a needle or cut out using a surgical procedure. A pathologist then examines and evaluates it under a microscope to identify noncancerous (benign) or cancerous (malignant) tissue.

Words used to refer to the abnormal area or growth before and after diagnosis may include lump, mass, lesion, calcification, and tumor.

Imaging studies such as mammography, magnetic resonance imaging (MRI), or ultrasound may be used to guide the procedure, known as an image-guided breast biopsy. A stereotactic breast biopsy uses a special mammography machine to help guide the biopsy equipment to the site of the breast abnormality.

The following are the different types of breast biopsy procedures:

• Fine-needle aspiration (FNA): A thin needle suctions out cells from an abnormal area; a physician examines the cells to see if cancer cells are present.
• Hollow or core needle biopsy: This thicker needle is used to remove a small cylinder of tissue from the abnormal area.
• Biopsy with a vacuum-powered device
• Surgical excision of tissue: This may be an excisional biopsy, in which all the abnormal area is excised or removed, or an incisional biopsy, which removes only a portion of the abnormal area for examination by the pathologist.

The breast biopsy is used to determine whether or not a worrisome abnormality or area of calcification is cancer and, if it is cancer, what type it is and how to develop a treatment plan. When no breast cancer is detected, the diagnosis of a benign or harmless lump is reassuring. The percentage of breast biopsies that are positive for cancer varies according to the individual hospital or clinic, but in general, only about 20% of breast lumps are cancerous. The majority of breast biopsies do not detect cancer.

Many physicians and health care professionals can be involved in evaluating a woman for a breast biopsy.

• For example, breast abnormalities during a physical examination might be noticed by a family physician, internist, gynecologist, or nurse practitioner. Women themselves are frequently the first to detect abnormalities in their breasts.
• Radiologists are specialists in interpreting X-rays such as mammograms, as well as other imaging studies. Radiologists or surgeons often perform the procedure to obtain these breast tissue samples.
• Anesthesiologists (specialists in administering anesthesia and monitoring a patient's vital signs) are sometimes necessary during some surgical procedures.
• Pathologists are physician specialists who examine and identify under a microscope the type of cells in the samples and determine whether or not cancer is present.

Anyone, female or male, with a suspicious breast growth, abnormality detected on imaging study, or other symptoms of breast cancer should undergo a biopsy. Ninety-nine percent of all breast cancers occur in females, however, males can and do get breast cancer. Therefore, men should regularly examine their breasts as females do for lumps or other cancer symptoms. (Males with the genetic disorder Klinefelter syndrome, which is associated with increased breast development, have approximately the same risk of developing breast cancer as females.)

Breast biopsies are performed in the doctor's office, an outpatient facility, or a hospital operating room. The setting depends on the size and location of the growth, the patient's general health, and the type of biopsy performed. Because physicians can perform biopsies in a short time with minimal risk of serious complications, the patient usually does not need to remain hospitalized overnight unless an underlying health problem requires close monitoring. A stereotactic breast biopsy uses mammography images to guide the location of the biopsy. Ultrasound or MRI imaging may also be used to guide the breast biopsy procedure.

Among the most common benign growths in the breast are cysts (sacs filled with fluid or semisolid material), intraductal papillomas (small wart-like growths that project above a tissue surface), and lumps formed by fat necrosis (the death of tissue often as a result of trauma to the breast). A fibroadenoma is the most common type of benign (noncancerous) breast tumor and is found in young women.

A suspicious breast growth may be found by a patient's self-examination, a physician's clinical examination, or a screening procedure such as a mammogram. Small calcium deposits, known as calcifications, are often identified in imaging studies of breast cancers and precancers. These may also be present in benign lesions.

Females and males (regardless of age) who discover a lump in a breast should see a doctor for testing. They also should see a doctor if they find a lump in an armpit or above a collarbone (either of which could indicate the presence of spreading cancer).

A doctor or health care professional should be consulted if a person has

• red or irritated breast skin,
• scaly skin on the breast,
• dimpling skin on the breast,
• swelling breast skin,
• nipple discharge other than milk,
• nipple retraction or inversion,
• nipple itching,
• a change in the size or shape of a breast, or
• breast pain.

It is important to remember that these signs and symptoms do not necessarily indicate the presence of cancer.

The patient should tell the health care professional when the growth appeared, what its size was at the time of discovery compared to its present size, and where it is located. The patient should also outline any family history of breast cancer, as well as any personal history of breast problems of any kind.

A physician confirms the presence of a growth by taking a medical history (and asking numerous questions), performing a clinical examination that includes palpating (feeling) the breast, and interpreting the results of a diagnostic mammogram and sometimes other imaging studies such as ultrasound or MRI.

Ultrasound sends sound waves into the breast that bounce back to a receiver that can record an image on a computer screen to visualize interior structures. This technique can help distinguish between a cyst and a solid growth. The physician may also order the laboratory analysis of any nipple discharge (other than milk) to examine for the presence of atypical or cancer cells. After confirming the presence of a suspicious growth or mass, the physician orders a biopsy.

For nonsurgical biopsies, the patient may need no anesthesia at all or just a local anesthetic (one that numbs the suspicious area only). Sometimes, a patient receives a sedative (calming drug) with local anesthesia.

For surgical biopsies, the patient may receive a local anesthetic (with or without a sedative) or general anesthesia (one that induces sleep). Patients requiring general anesthesia may have to fast eight to 12 hours before undergoing a biopsy.

Except for a minor sting from the injected anesthesia, patients usually feel no pain before or during a procedure.

The risk of complications, such as infection and bleeding, is small for nonsurgical procedures and slightly higher for surgical procedures.

After a procedure, some patients may experience some soreness and pain as well as bruising and minor skin discoloration of the breast that usually resolves within a week or so. Usually, an over-the-counter drug such as acetaminophen (Tylenol) is sufficient to alleviate any discomfort.

Generally, nonsurgical biopsies are less stressful, do not disfigure the skin, leave no internal scar to interfere with the accuracy of future mammograms, and minimize the risk of complications.

However, nonsurgical biopsies are not always as reliable as surgical biopsies in producing a diagnosis, and the results at times may be inconclusive. For this reason, some patients who undergo a nonsurgical biopsy must also undergo a follow-up surgical biopsy.

Breast biopsy procedures include

• fine-needle aspiration,
• core needle biopsy,
• vacuum-assisted breast biopsy, and
• surgical biopsy.

These procedures are described in greater detail later in this article.

A fine needle aspiration biopsy can be done in several different ways:

• Fine-needle aspiration (FNA) for palpable growths: A palpable growth is one that can be felt. The patient usually sits up while the doctor inserts a small hollow needle with a syringe to withdraw (aspirate) fluid and cells from the growth for testing. The doctor simply feels (palpates) the suspicious area to the needle to the site. When the needle reaches the mass, the doctor suctions out a sample with the syringe. The doctor repeats this procedure several times. If the mass is a cyst, the withdrawn samples will consist mainly of fluid and the cyst may collapse, relieving any pain the patient feels. If the mass is solid, the samples will consist primarily of tissue cells.

By analyzing the samples immediately after their withdrawal, a doctor may be able to determine that they came from a cyst and simply discard them, diagnosing the growth as benign. In all other cases, fluid and tissue samples are placed on slides and then analyzed by a pathologist in a laboratory. Atypical cells found in a fine-needle aspiration biopsy may signal that cancer is present or that repeat biopsies are necessary.

• Guided FNA for non-palpable growths: When a growth is too small or deep to palpate (feel), the doctor must locate it with one of several imaging techniques. First, the patient lies face-down on a table with the breasts suspended through an opening. With stereotactic mammography, mammograms of the suspicious breast site are taken from different angles to form a virtual three-dimensional (stereotactic) image that precisely pinpoints the location of the suspicious area. The computer then uses a motor to guide a small hollow needle to the site to remove the samples. The withdrawn samples are then analyzed for the presence of cancer. Ultrasound and MRI are other imaging techniques that may be used to guide breast biopsies.

A core needle biopsy can also be done in several different ways:

• Core needle biopsy for palpable growths: This procedure is similar to FNA for palpable growths except that that the needle used has a wider diameter and is equipped with a cutter that removes cores of tissue up to a ½ inch long. A key advantage of this procedure is that the samples are larger than in FNA and thus enhance the possibility of making an accurate laboratory analysis.
• Guided core needle biopsy for non-palpable growths: This procedure also uses a wide needle with a cutter that removes cores of tissue large enough to enhance the accuracy of laboratory analysis. However, because the growth is deep in the breast or otherwise not palpable, stereotactic imaging, ultrasound, or MRI is used to locate the growth.

Vacuum-assisted breast biopsy is procedure that uses a special instrument and imaging guidance to remove breast tissue samples through a single small skin incision. This technique allows the surgeon to remove more tissue through a single incision than is possible with a traditional core biopsy and is a much less invasive procedure than an open surgical biopsy.

The vacuum-assisted biopsy involves the placement of a biopsy probe using radiology imaging studies for guidance. Stereotactic mammography, ultrasound, and MRI have all been successfully used to identify the abnormal areas to be sampled by vacuum-assisted breast biopsy. Once the biopsy probe has been positioned, a vacuum pulls the breast tissue through an opening in the probe into the sampling chamber of the device. Then a rotating cutting device in the instrument removes the tissue sample, which is carried through the biopsy probe to a tissue collection receptacle.

The surgeon or radiologist then turns a control knob on the biopsy probe that moves the sampling chamber to a new position. This procedure is repeated until all desired areas have been sampled. In this way, samples can be taken all around a suspicious area through a single insertion of the biopsy probe. With a traditional core biopsy, sampling of multiple areas would involve repeated insertions of the biopsy instrument.

The vacuum-assisted biopsy procedure is performed under local anesthesia and leaves a small incision that does not require stitches for closure. It takes less than an hour to perform, and patients can usually return to normal activities soon after the procedure.

A surgical biopsy can be an excisional (removing the entire abnormal area) or an incisional (removing only part of the abnormal area) biopsy. The surgical biopsy can be done in different ways:

• Surgical biopsy of palpable growths (lumpectomy): This procedure removes part or all of a breast growth, or lump. The doctor makes an incision 1 or 2 inches (about 2.5 to 5 cm) across and removes the sample. If the lump is small and measures 1 inch (2.5 cm) or less across, the doctor usually removes the entire lump for testing (excisional biopsy). If the lump is large, the doctor usually removes only a portion of it for testing (incisional biopsy). If cancer is found, the rest of the lump can be removed at the time of the biopsy or at a later time.

The doctor closes the opening with sutures or clips that remain in place for about a week. Patients who receive general anesthesia rather than a local will require about an hour to recover from drowsiness after the surgery.

• Surgical biopsy for non-palpable lumps: This procedure is similar to lumpectomy except that the growth is first located by mammography or other imaging studies and then "marked." The doctor inserts a needle that conveys a wire with a hook on the end into the breast, all the while using the image as a guide. After anchoring the hooked wire to the lump, the doctor withdraws the needle and performs the surgery. Another option is to inject a dye to mark the spot rather than using a hooked wire.

For small biopsies and fine-needle aspirations, the results may be available the next day. The results of most breast biopsies will be available within a few days. Sometimes special testing must be performed, and the results may be delayed and take longer. This does not necessarily mean that a cancer is present. For example, sometimes the tissue sections must be recut to reveal deeper layers of the tissue to allow for optimal evaluation by the pathologist. In other cases, special tissue stains may be necessary to help the pathologist assess the tissue sample under the microscope. The radiologist or surgeon performing the procedure will be able to give you a better idea of the approximate time frame and how the result will be communicated to you.