BREAST BIOPSY: WHAT YOU NEED TO KNOW

Do I Need A Breast Biopsy? What Methods Are Available? What Are The Risks? What Happens Afterwards?

Do I need Biopsy? Mammograms and other forms of imaging (such as ultrasound) can detect abnormalities but sometimes it is not possible to determine if an abnormality is benign or cancerous. In order to do so, it is necessary to obtain a tissue sample (biopsy) for microscopic examination to arrive at a diagnosis. Not all findings on mammography or ultrasound will need to be biopsied. Your doctor may or may not recommend a breast biopsy depending on what the breast abnormality is. These are some factors which your doctor will take into consideration before deciding if you will need a breast biopsy. How suspicious the mammographic or ultrasound findings are Size of the abnormality on mammography or ultrasound A breast lump that is palpable (can be felt on examination) Age (the older you are, the higher the risk of breast cancer) Family or personal history of breast, ovarian or other cancers that may possibly be related Prior use of hormone replacement therapy • Noticeable change of the abnormal area during follow up (for example, rapid increase in size or change in characteristics or appearance) If there are other associated symptoms such as nipple discharge or rash, lumps in the armpit or neck region

What Methods Are Available? Fine Needle Aspiration (FNA) A fine gauge needle attached to a syringe is introduced through the skin to sample fluid from a breast cyst or to remove clusters of cells from a solid breast lump. The cellular material removed is then sent for microscopic analysis to determine if there are any cancerous cells. Sometimes fluid removed from a breast cyst may not be routinely sent for microscopic analysis. This is because the majority of such cysts are non-cancerous. Core Needle Biopsy A hollow needle device is introduced through a small skin nick measuring about 0.5 cm under local anaesthesia to obtain a tissue sample. For clearly palpable lumps, this can be done by fixing the lump with one hand while performing a freehand needle biopsy with the other. For non-palpable or vaguely palpable lumps, this can be done with the help of various imaging modalities. When done with the help of X-Rays, this is called stereotactic breast biopsy. In stereotatic breast biopsy, computer mapping is used to pinpoint the exact location of the abnormality based on mammographic images taken from 2 different angles. This then helps guide the needle to sample the exact area of abnormality. When done with the help of ultrasound, this is called ultrasound-guided breast biopsy. Using ultrasound guidance, your doctor visualizes the needle real-time on the ultrasound monitor as it is carefully guided to the area of abnormality. Modern technologies have now enabled this to be done with the help of MRI for abnormalities detected on MRI. This service is currently available at the KK Breast Centre. Vacuum-assisted biopsy To view a short video of Vacuum-assisted biopsy using Mammotome® Breast Biopsy System, click here. Like core needle biopsy, the vacuum-assisted biopsy involves introduction of a hollow needle device through a small skin nick (0.5 cm) under local anaesthesia to obtain the tissue sample under image (mammography or ultrasound) guidance. However, unlike the core needle biopsy, which involves repeated needle insertions through the same skin incision to obtain multiple tissue samples, the vacuum-assisted biopsy system only requires one pass through the skin and relies on the suction vacuum system to draw the surrounding tissue into a special trough of the hollow needle device. A built-in rotating cutting device is then advanced to cut and remove the tissue sample. This suction-cut cycle is repeated until the target area of abnormality has been sufficiently sampled. In cases where the area of abnormality is less than 2 cm, the entire lesion may be completed removed by such a procedure. The vacuum-assisted biopsy system currently available in KK Breast Centre is the Mammotome® Breast Biopsy System , marketed by Johnson & Johnson Medical Singapore. Open surgical biopsy This involves a small operative procedure with a skin incision (measuring an average of 2- 5 cm) to remove the whole lesion or a portion of the lesion for microscopic analysis. This can be performed as a day surgery procedure under local or general anaesthesia, but is usually more comfortable for the patient if done under general anaesthesia. This method was widely practised in the past but with the advent of modern imaging and minimally invasive equipment, many patients are suitable for less invasive biopsy procedures such as core needle biopsy or vacuum-assisted biopsy. In some cases, the surgeon will use image guidance (mammography or ultrasound) to help locate the area of abnormality with a wire marker prior to open surgical biopsy. This is referred to as “wire-localization”. It is done when the abnormality can only be seen on imaging tests and an image-guided core needle biopsy is technically difficult to perform or has been done but yielded non-conclusive results.

What are the risks? Breast biopsies are minimally invasive and the risks involved in the procedure are very low.  Common problems encountered after breast biopsies include: Bruising – this occurs around the lesion or around the skin incision. It is self limiting and takes about 1 week to resolve. Haematoma – this is due to pooling of blood in the biopsy cavity, due to bleeding from the tissue. It occurs more often in vacuum assisted biopsy, because of the larger volume of tissue that is removed. Most of the time it will be self limiting, although rarely if the bleeding is persistent you may require a second minor procedure to stop the bleeding. Infection – this is very unlikely for FNA, CNB or vacuum assisted biopsies. However, it may occur in excision biopsy procedures. It usually responds to a short course of antibiotics or dressing. Risks of general anaesthesia – if open surgical biopsy is performed under general anaesthesia. FNA, CNB and vacuum assisted biopsy is performed under local anaesthesia, so the risk is minimal; they can even be performed during pregnancy if necessary.

What happen afterwards? If you had a benign FNA or CNB result, your will not need to have the lump removed unless there are special circumstances, for example if the lump is very large or growing in size. Occasionally, despite the benign FNA or CNB result, your doctor may still advise removal of the lump if he feels that the lump is very suspicious but the FNA or CNB was unable to prove it. If the FNA or CNB shows that the lump is cancerous, then your doctor will discuss with you what cancer treatments are appropriate. This will usually involve surgery. Depending on the stage of the cancer and type of surgery, you may also require chemotherapy and/or radiotherapy after surgery. A diagnosis of cancer based on the FNA or CNB allows your doctor to discuss the various treatment options with you before appropriate cancer surgery. You will also have time to make your own choices and seek a second medical opinion if desired.