Taking a Percutaneous Biopsy of the Breast
‘Percutaneous’ means ‘through the skin’. Thus a percutaneous core biopsy involves the use of a needle to extract a small tissue sample from the tumor core for further microscopic evaluation.
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The reason that a percutaneous biopsy would be called for is basically because something, such as a possible tumor, was apparent at the screening and needs to be investigated and clarified. Percutaneous core biopsies are usually given for a BI-RADS category of 4 or higher. BI-RADS categories 3 and lower usually employ imaging followup rather than biopsies, unless there are very significant risk factors.
The percutaneous biopsy is typically guided by either an ultrasound or CT scan image, and usually up to 12 samples are taken. One practical advantage of the needle biopsy is that the patient takes virtually no time to recover, thus they can get on with their daily routine, or, proceed directly to chemotherapy or other recommended treatment course, without delay.
Percutaneous core biopsies are very sensitive, and have very low ‘false negative’ rates
A Percutaneous core biopsy is a very sensitive and accurate method of diagnosing tumors, with an initial diagnosis rate of around 97%. But, the percutaneous biopsy is felt to be slightly less reliable when diagnosing recurring cancer after treatment, with an overall accuracy rate of around 88%.
But another advantage of the percutaneous biopsy is that it is very useful in differentiating ‘false positives‘, in which the biopsy reveals that the lesion is the result of some other inflammatory or infectious process, and not cancer. The frequency of missed carcinoma or ‘false negative‘ readings averages around 2.8%. But approximately 70% of these missed carcinomas are identified immediately after biopsy, with the remaining 30% identified after a short delay.
Issues surrounding the percutaneous biopsy
Care must be taken not to displace any malignant epithelium away from the target lesion during any directional-assisted biopsy. Epithelial displacement can cause interpretive problems, because displaced ductal carcinoma in situ (DCIS) can mimic infiltrating ductal carcinoma. But in addition to interpretive issues, some experts believe that the use of the percutaneous technique is more likely than surgery to ‘dislodge‘ tumor cells and cause the cancer to spread, but this belief is controversial: held firm by some, dismissed by others.
Fine needle aspiration could possibly cause hematogenous dissemination of breast cells, hematogenous meaning ‘spread by the blood‘. This is sometimes called ‘cell seeding‘ or ‘tumor cell displacement‘. This displacement of tumor cells is found in about 32% of patients who receive a large-gauge needle core biopsy. However, displaced tumor cells tend not survive much longer than 28 days after excision.
Large gauge needle biopsy and subsequent radiation treatment
The potential for tumor cell seeding is one reason that radiation therapy often follows the percutaneous core tumor biopsy. But this is probably somewhat of an exaggerated concern. The local recurrence rate of malignancy might be 7% if no radiotherapy is used, but it would not necessarily have anything to do with cancer cell seeding.
It should be stressed, however, that there is no clear evidence to support a conclusion that tumor cell displacement from the percutaneous biopsy lead to accelerated tumor growth or spread. This kind of precautionary intervention is performed at some cancer clinics and not at others. Given that radiation therapy is rather hard on the body, the patient has a right to be informed as to whether radiation at this point is truly necessary, and to decline.
Other recommendations for follow up after needle biopsy
If the initial biopsy indicates a discord between imaging characteristic and histological findings then a repeat biopsy will usually be required. A full surgical excision is warranted if the percutaneous sample shows an atypical ductal hyperplasia (ADH). Atypical intraductal hyperplasia found at percutaneous biopsy leads to a finding of carcinoma about 28% of the time. Whether or not this finding should be followed up with a full excisional biopsy is a matter of debate.
A fibro-epithelial tumor is difficult to distinguish from a phyllode tumor or a radial scar. A radial scar is thought to have a 13% risk for breast cancer, but usually considered benign. A full surgical biopsy might also be recommended by the pathologist given a finding of atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS).
When to request an open surgical biopsy
Radiologists review the post-biopsy reports to make sure the histologic findings are a good match for what the imaging thought it would be. If there is a good correlation and a feeling that the situation is well understood and of low risk, an excisional biopsy is probably uncalled for. But, there is really no hard and fast rule as to what determines the need for the surgical biopsy instead of just a needle biopsy.
Some doctors would recommend the surgical biopsy for typical ductal hyperplasia, for the radial scar, or for ductal carcinoma in situ. If there is a pronounced radio-pathologic discordance, (something not consistent between the mammogram and the initial needle biopsy workup) as mentioned above, there will be a full biopsy. Basically, if a tumor is clinically or radiologically suggestive of malignancy by any combination of indicators, there will be a full surgical biopsy.
Additional risk factors and possible treatments for non-invasive lesions become part of a comprehensive management strategy.
For further reading, I suggest you visit this page to know about sentinel lymph node biopsy that is used in breast cancer staging.
- St. Jude Children’s Research Hospital 332 North Lauderdale St. Memphis, TN 38105-2794. http://www.stjuderesearch.org/
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