Introduction
If a suspicious lesion (tissue abnormality) is found in your breast, your doctor will typically request that a biopsy be performed. Biopsy is removal of a piece of infected tissue or part of a lesion for examination under a microscope. This is the only way to know if a lesion is benign (not cancerous) or malignant (cancerous).

Procedures
Depending upon the size, location, appearance and characteristics of the abnormality, biopsy is performed. Several methods include:

Open Surgical Biopsy
Open surgical biopsy involves using a wire as a guide and liberally removes the breast tissue around the localizing device through an open incision.
Disadvantages of Open Surgical Biopsy:

• Requires stitches and can leave a scar.
• Small mortality risk (due to risks of anesthesia).
• Moderate chances of bleeding, infection, wound healing problems.
• Fracture or migration of the localizing wire.

Additionally, scar formation within the breast that may persist for 12 months or longer and may complicate the interpretation of follow up mammograms.

Fine Needle Aspiration
Fine Needle Aspiration (FNA) uses a fine gauge needle (22 or 25 gauge) to which a syringe can be attached to sample fluid from a cyst. Sometimes FNA is done to drain a benign (non–cancerous) cyst. For non–palpable abnormalities, the FNA procedure is a done under image guidance (either sterotactic mammography or ultrasound). After the needle is placed into the breast in the region of the abnormality, a vacuum is created and multiple in and out needle motions are performed. Three or four passes are usually made. Smears are then made on glass slides and the specimens are fixed and stained. A pathologist can make the diagnosis very quickly. If the fluid extracted from the breast lump is clear, the lump is most likely benign (non–cancerous). Bloody or cloudy fluid is usually benign as well, although occasionally, it may indicate cancer.Prior to FNA, the skin of the breast is cleansed and then anesthetized with a small hypodermic needle. FNA requires no sutures (stitches) and can usually be done on an outpatient basis. A very small bandage is placed over the area afterwards. Many patients resume their normal lifestyle and routine the same day of the fine needle biopsy procedure.

Core Biopsy
During a core biopsy, small samples of tissue are removed from the breast using a hollow needle under image guidance (either stereotactic mammography or ultrasound). The needle is either placed by hand or with the assistance of a sampling device. Multiple insertions are needed to obtain sufficient breast tissue, usually multiple samples are taken. Patients may experience a slight pressure, but should not experience any pain. As tissue samples are taken, a click may be heard from the sampling instrument. Typically, several samples approximately 3/4 inches long and 1/16 inches in diameter are removed. The samples will be sent to the pathology laboratory for diagnosis.

Suction Assisted Biopsy
The suction assisted biopsy procedure is similar to core biopsy and is guided using stereotactic mammography or ultrasound imaging. However, unlike core biopsy, the special biopsy probe is inserted just once into the breast through a tiny skin nick in the patient’s breast. The sampling chamber of the probe is placed in the vicinity of the abnormality under image guidance. A vacuum line pulls tissue through the aperture and into the sampling chamber. Once tissue has been pulled into the chamber, a rotating hollow coaxial cutter is advanced and captures a tissue sample. The sample is then carried through the probe to the tissue collection area (a standard pathology tissue cassette). After the first sample is acquired, the orientation of the aperture is rotated by the physician to the next desired position. The sampling chamber is moved to a new position, the entire cycle is then repeated, until all desired areas have been sampled. The probe is then removed and pressure will be applied to the biopsy site and an adhesive bandage is applied to the skin nick. A pathologist then tests the tissue samples.

Large Core Breast Biopsy
The Large Core Breast Biopsy technique, is a surgical removal of the whole lesion (abnormality) intact by an invasive, disposable sterile probe. The large core breast biopsy procedure involves using a prone biopsy table and digital stereotactic imaging. During the procedure, a wire is guided into the lesion and then a cannula (narrow tube with a cutting device) is inserted into the breast with a probe to part and spare normal breast tissue. With the use of local anesthesia and while the breast is maintained in compression, the lesion is then removed with a looped wire and orientated for pathological study. Due to the size of the large core breast biopsy incision, stitches are typically required.The large core biopsy can remove a 10mm to 20mm tissue sample.


Image guided percutaneous (through the skin) biopsy is minimally invasive, causes little pain and requires no stitches. Each type of percutaneous biopsy (fine needle aspiration/FNA, core biopsy, suction assisted biopsy) is achieved through one of the following image guidance methods:

• Ultrasound Guided Breast Biopsy.
• Prone Stereotactic Breast Biopsy Guidance.
• Breast Biopsy Guidance Using Upright Stereotactic Mammography.

In each case, once the biopsy tissue samples are removed, they are analyzed by a pathologist to determine their type. Patients undergo image guided percutaneous biopsy procedures while awake. Many patients resume their normal lifestyle and routine the same day of the procedure.

Image Guided Percutaneous Biopsy Procedure

• Patients may eat a light breakfast prior to the exam and biopsy procedure.
• A comfortable two piece garment should be worn.
• Women should not wear talcum powder, deodorant, lotion or perfume under their arms or on their breasts on the day of the exam.
• Patients who take blood thinners and aspirin should discontinue using them prior to the exam (3 days for coumadin or other blood thinners, 7 days for aspirin or ibuprofen).
• Any jewelry worn (especially earrings or necklaces) should be easily and quickly removable, especially if the patient will undergo a prone (lying face down) procedure.
• The skin of the breast is cleansed and then anesthetized with a small hypodermic needle and a sampling needle is placed in the breast (under one of the three guidance methods: upright stereotactic imaging, prone stereotactic imaging, ultrasound imaging).
• Patients may experience a slight pressure, but should not experience any pain. Typically, several samples are removed.
• The samples will be sent to the pathology laboratory for diagnosis.
• The exam will last approximately one hour. During the procedure, the patient will be informed of what is occurring and what she will need to do to assist in the exam. There will be some minor bleeding when the needle is placed.

Breast Biopsy
After the Image Guided Percutaneous Biopsy Procedure

Breast MRI
• After the biopsy procedure, a bandage will be placed over the needle insertion area and a cold pack will be applied to relieve swelling or bruising.
• Patients may take Tylenol (two 500 mg tablets) every four to six hours, for discomfort, if needed.
• Patients may notice some bruising of the area that should dissipate in 5–7 days (or longer if initial bleeding was greater than usual).
• Patients should contact their physician if they experience any excessive swelling, bleeding, drainage, redness, or heat in the area of the biopsy or breast.
• Patients should discuss the final results of the breast biopsy procedure with their referring physician within a few days of the procedure.

Ultrasound Guided Biopsy of the Breasts
Ultrasound is an excellent method of imaging the breasts and ultrasound guidance allows biopsy of the breast from almost any orientation. During an ultrasound–guided biopsy, small samples of tissue are removed from the breast using a hollow needle that is precisely guided to the correct location using continuous ultrasound imaging. During the exam, the patient will lie face up on the standard ultrasound table while being modestly draped exposing only the area of the breast undergoing biopsy. The area is identified by a preliminary ultrasound and then the breast is cleansed and draped.

Prone Stereotactic Breast Biopsy Guidance
During a prone stereotactic core biopsy, the patient lies face down (prone) on a specially designed table with the breast placed through an opening in the tabletop. “Stereotactic” means that the breast biopsy path is imaged from two slightly angled directions to help guide the needle. The tabletop is raised and the radiologist and technologist perform the procedure from beneath. The patient’s breast is slightly compressed and held in position throughout the procedure. Several stereotactic pairs of x–ray images are made. Small samples of tissue are then removed from the breast using a hollow needle that is precisely guided to the correct location using x–ray imaging and computer coordinates.

The radiologist and technologist perform a prone stereotactic biopsy while the patient lies comfortably.

Breast Biopsy Guidance Using Upright Stereotactic Mammography
Breast biopsy using upright stereotactic mammography requires the patient to sit upright in a chair or to lie on their side (lateral recumbent position). The breast biopsy path is imaged from two slightly angled directions to help guide the needle using an upright stereotactic mammography system. The patient’s breast is slightly compressed and held in position throughout the procedure. Several stereotactic pairs of x–ray images are made. Small samples of tissue are then removed from the breast using a hollow needle that is precisely guided to the correct location using x–ray imaging and computer coordinates. Perhaps the most difficult part of this procedure for many patients is the need to sit upright without moving during the biopsy.

The patient is in the lateral recumbent position for biopsy using an upright stereotactic mammography system. The patient is in the seated position during biopsy using an upright stereotactic mammography system.

Indications

• Abnormality detected by a mammogram.
• A lump found by a woman or her doctor during a breast examination, may or may not be cancerous.
• Non–palpable breast abnormalities (lumps that can not be felt).