Breast Core needle biopsy procedure

Patients undergo breast core biopsy generally due to one of the 3 main reasons:

1) Presence of a mass or mass-like lesion either clinically palpable or diagnosed on imaging.
2) Presence of suspicious calcifications on screening mammography.
3) Nipple discharge or skin/nipple changes.

Advantages of breast core needle biospy over Fine needle aspiration cytology (FNAC) are as follows:

•Most cases can be definitely categorised
•Provides architectural information
•Microcalcifications can be directly visualised

The biopsy techniques and imaging modalities used by radiologists vary and is generally dependent on the type of lesion, most suitable method for visualization, and patient related factors.
• Calcifications are most obvious on screening mammograms and are amenable to stereotactic core biopsy.
• A mass lesion is generally best seen under ultrasound (US) guidance

Imaging modality used for biopsy are :-
• Stereotactic
• Ultrasound (US)
• Magnetic Resonance Imaging (MRI)

Stereotactic breast core needle biopsy :
–Uses X-ray imaging for localizing and targeting a lesion
– Calcifications and masses visualized on a mammogram can be biopsied
– Patient is placed in prone or upright position
– Generally performed using a Vaccume Assited Device (VAD)
– Needle gauges range from 7-14 depending on the lesion biopsied

Not all mammographically detected lesions/changes are biopsied. Radiologists use a method of scoring called Breast Imaging and Radiologists Scoring (BI-RADS) system to assess if the lesion identified on imaging requires a biopsy. Any lesion with a score of 4 is biopsied.

Ultrasound (US) guided core biopsy offers several advantages over stereotactic biopsy.
1. US is a real time procedure, i.e. it is possible to follow the motion of the biopsy needle as it moves through the breast tissue.
2. Since it does not require breast compression, US guided core biopsy procedure may be more comfortable to the patient.
3. US guided biopsy is faster, cheaper, avoids ionizing radiation and allows biopsy of areas hard to reach (under the arm or close to the chest wall) via stereotactic biopsy.

Ultrasound guded biopsy

Some difficult to see lesions are generally more obvious under magnetic resonance imaging (MRI). MRI is also used in some high risk patients to detect early lesions. Some breast centers have also started using bilateral breast MRI after the diagnosis of invasive cancer to exclude the possibility of multifocal disease, although the significance of this practice is currently debated. MRI guided core biopsies are more cumbersome than other methods and requires administration of gadolinium and therefore cannot be performed in pregnant patients.

Type of biopsy devices used for biopsy-

– Automated large core (ALC)

– Vacuum assisted device (VAD)

– Total removal device (TRD)

The type of biopsy devices used may also vary by the type of imaging technique employed to perform the procedure. The vacuum assisted devices (VAD) have largely replaced automated large core (ALC) devices for stereotactic and MRI guided biopsies, but ALC devices are still used for US guided core biopsies. ALC with 14-gauge needle or a VAD with 7-14 gauge needle can be used in an US guided core biopsy A VAD offer several advantages over ALC devices. VAD allows single insertion of the needle to obtain large amount of tissue which results in more accurate diagnosis and less false negatives. To further reduce the underestimation of disease, total removal devices (TRD) have recently been introduced that can be used under stereotactic or US guidance. This biopsy system requires an 8 mm skin incision and removes an intact portion of breast tissue preserving the architecture of the lesion. More experience is required for its diagnostic and therapeutic use.

Breast Biopsy -video