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.

A Pathologist interprets the results of a breast biopsy and this is called a ‘histological workup‘.

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Why take a Percutaneous Core Biopsy?

If something unusual shows up on breast cancer screening, such as a possible tumour, then a percutaneous biopsy may be necessary.

The biopsy is a further investigation and clarification of any abnormality on a mammogram.   Doctors will take a percutaneous core biopsy for a BI-RADS category of 4 or higher. 

However, BI-RADS categories 3 and lower usually employ imaging followup rather than biopsies, unless there are very significant risk factors.

Doctors will use either an ultrasound or CT scan image to guide the biopsy 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, patients can get on with their daily routine.  Sometimes patients will continue directly to chemotherapy or other treatment 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. 

Indeed, the core biopsy has an initial diagnosis rate of around 97%.  However, the percutaneous biopsy is slightly less reliable when diagnosing recurring cancer after treatment.  In the latter case, the overall accuracy drops to around 88%.

But another advantage of the percutaneous biopsy is that it is very useful in differentiating ‘false positives’.  A false positive is whereby the biopsy reveals that the lesion is the result of some other inflammatory or infectious process and is not cancer.

The frequency of specialists missing cancer or a ‘false negative’ reading is around 2.8%. But doctors will identify approximately 70% of these missed carcinomas immediately after biopsy.  Thus, medics will identify the remaining 30% after a short delay.

Problems with the Percutaneous Biopsy

During any biopsy, care must be taken not to displace any malignant epithelium away from the target lesion.  Epithelial displacement can cause interpretive problems because displaced ductal carcinoma in situ (DCIS) can mimic infiltrating ductal carcinoma.

In addition to interpretive issues, some experts believe that the use of the percutaneous technique is more likely than surgery to ‘dislodge’ tumor cells thus causing cancer to spread.   However, this belief is controversial: some doctors hold it firm whilst others totally dismiss it.

Fine needle aspiration can possibly cause hematogenous dissemination of breast cells.  So,  hematogenous means ‘spread by the blood’.   This is sometimes called ‘cell seeding’ or ‘tumor cell displacement’. 

So, the displacement of tumor cells occurs in about 32% of patients who receive a large-gauge needle core biopsy. However, these tumor cells tend not to 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 an over-cautious step.

The local recurrence rate of malignancy maybe around 7% with no radiotherapy follow-up.  However, this may not necessarily have anything to do with cancer cell seeding.

It is important to stress, however, that there is no clear evidence to support that tumor cell displacement from a biopsy leads to an acceleration in tumor growth or spread. 

Indeed, some cancer clinics perform this kind of precautionary intervention, whilst others do not. Given that radiation therapy is rather hard on the body, the patient has a right to accurate information on 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 necessary. 

A full surgical excision is necessary if the percutaneous sample shows 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 a full excisional biopsy is necessary as a follow-up remains a matter of debate amongst medics.

A fibro-epithelial tumor is difficult to distinguish from a phyllode tumor or a radial scar. A radial scar has around a 13% risk for breast cancer, but medics usually consider it to be benign.   

The pathologist might also recommend a full surgical biopsy if there is 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 with the imaging findings.  If there is a good match and low risk, an excisional biopsy is probably not necessary. 

However, there is really no hard and fast rule as to what determines the need for a surgical biopsy instead of just a needle biopsy.

Some doctors recommend a surgical biopsy for:-

• typical ductal hyperplasia
• radial scar
• ductal carcinoma in situ.

If there is a radio-pathologic discordance, (something not consistent between the mammogram and the initial needle biopsy workup)  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.

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Further Reading

• Core Biopsy of the Breast: Everything that you need to know
• Breast Biopsy after an Abnormal Mammogram
• Stereotactic Breast Biopsy
• Post Biopsy Mammogram
• Sentinel Lymph Node Biopsy
• Full Index of ALL our Posts on Breast Cancer Screening
• Staging of Breast Cancer ALL our Posts

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References

• St. Jude Children’s Research Hospital 332 North Lauderdale St. Memphis, TN 38105-2794. http://www.stjuderesearch.org/
• Gal-Gombos EC, Esserman LE, Recine MA, Poppiti RJ. Large-needle core biopsy in atypical intraductal epithelial hyperplasia including immunohistochemical expression of high molecular weight cytokeratin: analysis of results of a single institution. Breast J2002; 8:269 274
• Brenner RJ, Jackman RJ, Parker SH, et al. Percutaneous core needle biopsy of radial scars of the breast: when is excision necessary? AJR 2002;179:1179 1184
• LK Diaz, EL Wiley and LA Venta . Diaz. LK, Wiley. EL, Venta. LA, Are malignant cells displaced by large-gauge needle core biopsy of the breast? Department of Pathology, Northwestern University Medical School, Chicago, IL 60611, USA.
• Thurfjell MG, Jansson T, Nordgren H, Bergh J, Lindgren A, Thurfjell E. Local breast cancer recurrence caused by mammographically guided punctures. Acta Radiologica 41 (5):435-40, sept. 2000.
• Hu XC, Chow LW. Fine needle aspiration may shed breast cells into peripheral blood as determined by RT-PCR. Oncology. 59 (3):217-22, Sept. 200.

More References

• Stolier A, Skinner J, Levine E. A prospective study of seeding of the skin after core biopsy of the breast. The American Journal of Surgery Vol. 180 (2). August 2000, 104-107.
• Jackman RJ, Nowels KW, Rodriguez-Soto J et al. Stereotactic, automated, large-core needle biopsy of nonpalpable breast lesions: false-negative and histologic underestimation rates after long term follow-up. Radiology 1999;210:799-805.
• Liberman L, Clinical management issues in percutaneous core breast biopsy Radiologic Clinic of North America, Vol.38, no4, July 2000, p 791-807
• Barreau B, Tastet S, Lakdja F, Henriquès C, Valentin F, Labat MJ, Dilhuydy MH. Patients’ information in percutaneous core breast biopsy. Bull Cancer. (Mar. 2005) 92(3):257-65.
• Johnson, NB., Collins, LC. Update on Percutaneous Needle Biopsy of Nonmalignant Breast Lesions. Advances in Anatomic Pathology: (July 2009)- Volume 16 – Issue 4 – pp 183-195
• Resetkova E, Edelweiss M, Albarracin CT, et al. Management of radial sclerosing lesions of the breast diagnosed using percutaneous vacuum-assisted core needle biopsy: recommendations for excision based on seven years’ of experience at a single institution. Breast Cancer Res Treat. (2008). Jul 15, e-pub.
• Becker L, Trop I, David J, et al. Management of radial scars found at percutaneous breast biopsy. Can Assoc Radiol J. (2006);57:72–78.