Breast-nonmalignant - Core biopsy

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Breast-nonmalignant

Procedures

Core biopsy of breast lesions

Editor: Hind Nassar, M.D., Johns Hopkins Medical Institute (see Reviewers page)

Revised: 26 September 2012, last major update April 2010

General

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● See also discussion of core biopsies under specific diagnoses and core biopsy imprint cytology as part of cytology topic

● Percutaneous large core needle biopsy using stereotactic mammography or ultrasound guidance is routinely used to evaluate clinically occult breast lesions, and is an alternative to open biopsy for many patients

● Recommended as the initial diagnostic procedure in patients with suspicious mammograms, due to association with improved pathologic margins and fewer surgical procedures (Breast J 2008;14:471)

● May be an alternative to surgery for some lesions (Breast 2008;17:546, Radiology 2008;248:406)

● Has led to reduction in surgical interventions after benign or negative diagnoses (Eur J Cancer 2008;44:2580)

● Overall high level of inter-pathologist agreement (Am J Surg Pathol 2004;28:126)

● Diagnostic performance is comparable to excisional specimens (Int J Cancer 2008;122:468) but tumor grade in invasive carcinoma may differ (Am J Surg Pathol 2003;27:11, Am J Surg 2008;197:266)

● Performing imprint cytology on core may be useful for rapid diagnosis (Cytopathology 2008;19:311)

Core biopsy versus fine needle aspiration biopsy

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Core biopsy is favored over fine needle aspiration because core biopsy:

● (a) is useful for evaluating cytologic and architectural characteristics and diagnosing invasive carcinoma (Diagn Cytopathol 2007;35:681)

● (b) is more reliable (Acta Radiol 2008;49:863)

● (c) reduces need for additional biopsies (Acta Oncol 2008;47:1037)

Technical details

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● First generation: computer-assisted stereotactic mammography or ultrasound used to localize target lesion, then automated spring-loaded biopsy gun was used, usually with 14-gauge cutting needle

● Second-generation: includes Mammotome (Breast Cancer 2007;14:292, World J Surg Oncol 2007;5:83); uses vacuum assistance to draw tissue into the needle and permits use of larger-caliber needles (8 to 11 gauge) and more thorough sampling of lesions (thicker, longer, multiple specimens with single needle insertion)

● Processing: should routinely obtain 3-5 deeper levels; 5 levels recommended to detect ADH and atypical proliferations (Archives 2001;125:1055) or minimally invasive carcinoma (Archives 2004;128:996); but see Mod Path 2001;14:350

● May need only one level routinely for MRI detected lesions (Arch Pathol Lab Med 2009;133:1961)

● Underestimation of findings compared to excision is comparable with 9 or 12 gauge needles (Breast Cancer 2010 Mar 4 [Epub ahead of print])

● Some recommend routine radiologic examination of cores for microcalcifications and deeper levels if microcalcifications are not in slide

● Minimal invasion in core biopsies (1 mm or less) is usually associated with invasive tumors of 1 cm or more at excision (Archives 2004;128:996)

● Rarely mastectomy (or excisional biopsy) after malignant core biopsy will show no cancer (Mod Path 1997;10:1209)

● Immunostains for ER, PR and HER2 show 85-95% concordance with excision specimens (Acta Oncol 2008;47:38, Pathology 2007;39:391); substantial discordance for PR in some studies (Ann Oncol 2009;20:1948)

● Not associated with significant bleeding in patients on anticoagulant therapy (AJR Am J Roentgenol 2008;191:1194)

● Cytopathologists may be able to perform ultrasound guided FNAs and core biopsies (Diagn Cytopathol 2008;36:317)

False negatives

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● Radiologic-histologic correlation: must determine if histologic results provide a sufficient explanation for the imaging features - if not, lesion may not have been adequately sampled

● Most false negatives are due to radiologic-histologic discordance, and are discovered immediately (Eur Radiol 2010;20:782, Eur J Cancer 2010 Apr 12 [Epub ahead of print])

● Follow up imaging is recommended, even in patients with concordant benign findings (Radiographics 2007;27:79)

Complications

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● (a) seeding / displacement of normal epithelium along needle tract, particularly with papillary lesions, which may simulate malignancy (Archives 2005;129:1465)

● (b) seeding of tumor cells along needle tract (Breast Cancer Res Treat 2008;110:51), particularly intracystic papillary carcinoma (J Clin Pathol 2002;55:780)

● (c) seeding of tumor cells into lymphovascular spaces (Am J Clin Pathol 2010;133:781)

● (d) reactive spindle cell proliferation

● (e) epidermal inclusion cysts (image)

● (f) pseudoaneurysms are rare (Breast Cancer 2010;17:75)

Reporting system of UK National Health Service Screening Programme

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B1 - normal tissue/inadequate sample (comment on microcalcifications and specimen adequacy)

B2 - benign lesion (specify)

B3 - uncertain malignant potential (includes radial scar, some papillary lesions, ADH, lobular neoplasia)

B4 - suspicious of malignancy (suggestive but not diagnostic due to scanty material or artifacts)

B5 - malignant; specify if invasive or not, if possible; indicate grade of DCIS

References: J Clin Pathol 2004;57:897

Clinical images

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Mammotome

Micro images

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Displaced epithelial cells #1 #2-intracystic papillary carcinoma

Core biopsy with atypical hyperplasia (various)

Additional references

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● eMedicine, Breast fine needle aspiration cytology and core biopsy; a guide for practice 2004

End of Breast-nonmalignant > Procedures > Core biopsy of breast lesions

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