The world of breast cancer seems to change daily. Radiologists who once had only mammograms now add digital mammograms, ultrasounds, and MRIs to their arsenal. Chemotherapy drugs now include anti-hormone agents such as tamoxifen and aromatase inhibitors and gene-directed therapy such as herceptin. Partial breast irradiation is an option for some women. And surgery has evolved from the brutal Halstead radical mastectomy to lumpectomies with sentinel node biopsies. As fast as you blink, something new is on the horizon.
The choices for an initial breast biopsy have also changed. Gone are the days when every woman needed an operation to investigate every newly found lump or mammographic abnormality. Today, most biopsies can be accomplished without a surgeon’s knife, but don’t totally forget about us surgeons—we still play a big role in breast cancer therapy. However, with better biopsy techniques, we can reduce the number of surgeries a woman needs in her battle against breast cancer.
The scenario that leads to a breast biopsy usually starts with either a palpable lump or an abnormal mammogram with no palpable findings. Before any biopsy, the appropriate initial workup is a mammogram and often a breast ultrasound as well. The mammogram tells the radiologist whether there is an architectural distortion, a nodule/mass, or just abnormal calcifications. The ultrasound often helps distinguish a solid mass from a simple or complex cyst.
In the case of a simple cyst, usually no more workup is needed. Simple aspiration can be done if the cyst is big enough to be bothersome to the patient and is usually all that is required. However, if the cyst has solid components or if there is a solid nodule or worrisome calcifications, a biopsy is needed and the standard of care in today’s world is a minimally invasive image-guided core biopsy. This can be accomplished by an ultrasound-guided core biopsy (if the lesion is visible on ultrasound) or a stereotactic (mammogram-guided) biopsy (if the lesion can only be seen on mammography). Both are outpatient procedures, require only local anesthetic, and leave a very small incision which is closed with a Steri-Strip™. Both are well-tolerated, and the biggest side effect is bleeding, which can range from a simple bruise to a larger hematoma. Most are performed by radiologists, although some surgeons also do these types of biopsies either in the radiology department or with ultrasound equipment in their office. Both of these biopsies have largely replaced the older fine needle aspirates (FNAs), which have a higher false negative rate, are very operator dependent, have a hard time telling grade and invasiveness of a cancer, and can have difficulties with lobular cancers.
The advantage to these biopsies is that they give the surgeon a lot of information (type of cancer, invasive or not, etc.) so that we can plan definitive care with the patient and minimize their trips to the operating room. In the case of benign biopsies, which actually make up 70-85% of breast biopsies, they give us the diagnosis with excellent accuracy without a large incision and minimize recovery time for the patient.
Occasionally, surgical biopsies are still the way to go. This may be the case in a lesion that is too near the skin or too near the chest wall for the core biopsies. Some women with a fear of needles request surgical biopsies for the sedation/anesthesia. And if your pathology results and your radiology results don’t correlate (i.e., a benign path report when the radiology findings were suspicious for malignancy), you MUST be suspicious that the biopsy missed a malignancy and an open surgical biopsy is indicated in that case.
Ultrasound-guided biopsies are also being used to biopsy suspicious lymph nodes in the axilla to help with surgical planning. These biopsies can be fine needle aspirates (FNAs), or core biopsies are being used as well.
If you have any questions regarding what type of biopsy to order for your patient, always feel free to refer your patient to a general surgeon pre-biopsy. In many cases, that is helpful because we get a chance to examine the patient before any biopsy hematoma makes the exam confusing. And we are always happy to help plan the best biopsy for your patient for a quick and accurate diagnosis and a speedy recovery.
Dr. Elizabeth de Fluiter received her medical degree from the James H. Quillen College of Medicine, where she also completed a general surgery residency and research fellowship.
She is a Fellow of the American College of Surgeons and is board-certified by the American Board of Surgery. Dr. de Fluiter enjoys snow skiing, waterskiing, reading, and spending time with her husband and three children.