Breast Biopsies- Everything you never wanted to know
When the mammogram, ultrasound and/or MRI are inconclusive, what’s a radiologist to do? Phone a friend and enlist the help of a pathologist to get a look at the area of concern on a microscopic level! Biopsies answer the question ‘what is causing this change?’ with a definitive answer. Here’s what to expect when a biopsy has been recommended.
What is a biopsy?
A breast biopsy is a non-surgical way to obtain a small amount of tissue. This is done to make a conclusive diagnosis when imaging findings are either not definitive or worrisome. The goal of a biopsy is not to completely remove the area of concern but instead to get a representative look at the tissue in the area so your healthcare team can have more information and can tailor their recommendations for your care. For breast biopsies, a small needle biopsy device to obtain the tissue. Breast biopsy are most accurate when they are performed with image guidance so that the area of concern can be specifically targeted. Using imaging to guide a biopsy device has the added benefit of decreasing potential complications such as excessive bleeding since imaging can help the radiologist avoid nearby blood vessels. For many patients, an image guided breast biopsy allows the patient to avoid breast surgery. Depending on the results of the biopsy though, a larger area of tissue may need to be removed by a surgeon at a later time.
If a biopsy is recommended, does that mean I have cancer?
While biopsy is the procedure used to definitively diagnose breast cancer, the majority of breast biopsies result in non-cancerous or benign findings. In fact, between 75-85% of breast biopsies end up having non-cancerous results. Unfortunately, there is overlap in the imaging appearance of many of the early signs of breast cancer with other noncancerous findings in breast tissue and many times biopsy is the only way to tell the difference. It is recommended that a biopsy be considered for any breast imaging finding where the chance of cancer is greater than 2% because of this overlap in appearance for cancerous and noncancerous findings! While it is very important to proceed with biopsy when one has been recommended, rest assured that the likelihood of getting a favorable result back from that biopsy is usually higher than the likelihood of being diagnosed with cancer for most patients.
Are there different types of breast biopsies?
Yes! Depending on the size of a finding, its imaging appearance, and its location in breast tissue there are different types of breast biopsy that the radiologist may recommend for your specific situation. Breast biopsies are most accurate when guided by imaging. Different types of image guidance for biopsy include ultrasound, stereotactic (2-D mammogram), tomosynthesis (3-D mammogram), and MRI. Your radiologist will determine the best type of imaging guidance for you based on the finding that needs to be biopsied and other factors specific to you.
Fine-needle aspiration (FNA): This biopsy is done with a very thin needle and syringe to draw out a sample of breast cells or fluid to be examined. This type of sampling may be recommended for masses that have a fluid component, for findings that are in a tricky location surrounded by many structures that need to be undisturbed, or for patients that have a higher risk of bleeding complications. The benefit of a fine needle aspiration is that it typically causes less bruising and tenderness because the needle is so small. The drawback of a fine needle aspiration compared to other biopsy types is that the chance of incomplete or unrepresentative sampling is higher because such a small amount of tissue taken.
Core needle: This biopsy uses a larger (but still small!) needle than an FNA biopsy, and is also usually done with some type of imaging guidance. A small incision is made for the biopsy device to easily pass through the skin, but the incision is so small that only a bandage (no stitches!) is needed. There are many different types of core-needle biopsy devices, but many of them have a spring-loaded mechanism that sounds a bit like a stapler when the tissue sample is taken. Your radiologist will warn you before the loud click from sampling occurs and you will be given local anesthetic or numbing medicine at the biopsy site to minimize any discomfort. Multiple samples are taken from different parts of the targeted finding to make sure the pathologist has enough tissue to see the overall picture. With spring-loaded biopsy devices, the device will be removed from the breast tissue after each sample is taken so it can be collected for the pathologist. Often, the radiologist will place a guide, sometimes called a trocar, at the begining of the procedure. A trocar is basically a hollow tube that will stay in the breast tissue lined up at the site of concern. The biopsy device can then be quickly and easily taken in and out of the breast tissue through the trocar. This makes the procedure quicker and significantly reduces the risk of any cells from the biopsy site being displaced into a different part of the breast. This type of tissue sampling is usually performed with ultrasound guidance.
Vacuum-assisted core: During this biopsy, a doctor makes a small incision and inserts the biopsy needle device. The needle device then stays in position, but rotates as vacuum suction obtains multiple samples of breast tissue with the vacuum-powered device. This method removes more tissue than a spring-loaded core biopsy and is usually performed with mammogram or MRI guidance, but can be used with ultrasound guidance too. As more tissue is removed, the pathology results are more likely to give a conclusive result, but the trade-off is that bruising and tenderness after the procedure is more likely.
Excisional or incisional: This type of biopsy involves surgery to remove a finding or lump in your breast. Excisional breast biopsies remove an entire finding and surrounding tissue, while incisional breast biopsies remove only a portion of a finding. Surgical breast biopsies are reserved for findings that are not seen on imaging, findings that can not be safely or adequately sampled with needle biopsy techniques, or cases where the needle biopsy results are not conclusive. While lumps that are felt by you or your doctors do not need to be localized with imaging before surgery, if surgical biopsy has been recommended for an imaging finding, your radiologist may recommend marking or localizing the area of concern with imaging guidance to help guide the surgeon. While a surgical biopsy is the most accurate because it takes out most if not all of the area of concern, surgical biopsies are more involved procedures often requiring anesthesia, stitches, and a longer recovery time. Because of this, your healthcare team will try to do image-guided needle biopsy before going to surgical biopsy in most cases.
Why do I need to have a biopsy clip marker?
Placing a biopsy clip or marker is an important part of the biopsy procedure that is typically done at the end of tissue sampling and for the benefit of the patient. The marker is small, about the size of an eyelash, and will stay in the breast tissue to show where a biopsy has been performed. If you have more than one breast biopsy, the clip markers come in different shapes so that each biopsy site will have a unique marker. Clip markers can be seen on the different types of breast imaging and can help the radiologist compare findings on the mammogram, ultrasound, and MRI exams to see if they are caused by the same process. This is very helpful because breast tissue is in different positions for each of these exams which can make comparison between exams difficult. If the biopsy returns favorable, noncancerous results that do not require additional workup, the clip will be seen on all future breast imaging. Even though the imaging finding that prompted the biopsy may still be present in some way, additional testing for the finding can be avoiding as long as the finding is stable if the clip from a benign biopsy is present in the center of the finding. Think of the clip marker as your ‘get-out-of-additional-biopsy-free’ card. On the other hand, if the biopsy result shows cells that need to be removed from the breast the biopsy clip will serve as a target for surgical removal to make sure that the correct tissue is removed. In that case, you don’t keep the biopsy clip as a long-term souvenir. The biopsy clip marker is usually made from titanium, but it will not set off metal detectors and you can still have an MRI exam in the future. Once the clip is placed, you will not be able to see or feel it because it is so tiny.
What do I need to know before my biopsy?
To prepare for your procedure there are many considerations for both you and your care team.
Review your medication list with the radiologist. Some medications can thin the blood and make bleeding more likely during procedures. In addition to prescription blood thinners like warfarin, some over the counter drug such as aspiring and ibuprofen can increase the amount of bleeding during the procedure. Ask when and if any of your medications should be held for the procedure.
Let the radiologist know of any medication allergies. You will be given a local numbing medicine or anesthetic to minimize discomfort during the procedure. If you have an allergy, a different type of numbing medicine can be used, but the clinic may need to plan ahead to have the safest medication for you on hand.
Ask questions! At GRACE it is our priority to ensure that patients are well informed and comfortable with their healthcare. If there are any concerns that are lingering before the procedure, the technologist and radiologist are available both before and during the procedure to answer your questions.
Pick the right outfit. Select a two-piece outfit that is comfortable. It is recommended that the top be loose-fitting and easy to take on/off. A shirt that buttons down the front usually works well. A comfortable bra is a good idea.
Prepare yourself. It is a good idea to empty your bladder before the procedure starts to make sure you are more comfortable. It is recommended that you eat a light snack before your procedure, but not a large meal. Having a little bit of food helps prevent what is called a vasovagal reaction where you will start to feel lightheaded. However having too much food in your stomach may make your stomach feel uncomfortable or upset, especially if you are in a position where you will be lying on your stomach.
Plan the rest of your day. You will be in the clinic for 60-90 minutes for your procedure. You usually do not need someone else to drive you to and from the appointment, but you are welcome to bring a support person with you on the day of the procedure if you would like. An exception to this would be if you have taken a prescription anti-anxiety medication for an MRI biopsy- in that case a driver would be recommended. While not required, many people will make arrangements so they do not need to return to work after the procedure.
What will happen during the procedure?
First, we will have a “time-out” safety check. With everyone in the procedure room, we will confirm your name, birthday, the procedure to be performed, and any medication allergies.
If you need an IV placed to give contrast for the procedure in the case of an MRI-guided biopsy or Contrast enhanced mammogram guided biopsy, the IV will be placed before moving to the imaging machine.
Before the procedure starts, the technologist will help you get into the position that works best for the type of procedure you are having and the location of the finding that needs to be biopsied. For ultrasound guided biopsies you will typically lie on your back or on your side with your arm positioned to the side or above your head. For mammogram guided biopsies you will either sit upright in a chair or lie on your side with your breast in compression. For MRI-guided biopsies you will lie on your stomach on a special table attached to the MRI machine. The breast tissue will be placed into compression for the MRI guided procedure. Let your technologist know if there is anything we can do to make you as comfortable as possible before the biopsy starts.
Initial imaging of the area of concern will be taken to plan the approach of the biopsy device. The radiologist will select the best approach for you. For very subtle findings or findings that are very close to areas the the radiologist does not want to disturb with the biopsy, multiple images may be taken to optimize the positioning.
The skin over the area to be biopsied will be cleaned with sterile soap. Sterile towels will be placed about the rest of the body. Using sterile technique during the procedure helps to minimize the risk of infection.
The skin and the tissue around the area to be biopsied will be numbed with a local anesthetic. Once the anesthetic is working, you should only feel a light pressure or tugging during the rest of the procedure. If you need more numbing medicine, let the radiologist know!
Next, imaging is used to guide the biopsy device into position. Multiple small samples will be obtained and sent to the pathology lab for evaluation. Images are taken before and after each sample to show exactly where the tissue sample were obtained. If you are having a biopsy of calcifications, the radiologist may take an x-ray picture of the tissue that is removed to show that the tissue contains the calcifications of concern. This part of the procedure is the quickest and typically takes less than 5-10 minutes.
After an adequate number of samples has been acquired, the biopsy clip marker will be placed into the biospy cavity for future monitoring.
All devices will be removed by the radiologist and the technologist will hold light pressure on the biopsy site to minimize any bleeding. After the technologist has completed holding pressure, the area will be dressed with a special bandage.
Before you leave the imaging center, a very light compression mammogram will be performed to confirm the positioning of the biopsy clip.
After biopsy care instructions
You will be provided a reusable ice-pack that fits in a bra. Apply the ice pack to the biopsy area in 30 minute intervals for the next 2-3 hours.
The numbing medicine typically lasts for 1-2 hours. If you experience discomfort, acetaminophen (Tylenol) is the preferred over the counter pain reliever. It is recommended that aspirin and other non-steroidal anti-inflammatory medications such as ibuprofen (Advil) are avoided for the first 24 hours after biopsy.
Avoid getting the biopsy area wet for the first 24 hours. After 24 hours you may shower, but it is a good idea to avoid soaking/submerging the biopsy area with swimming/hot tubs for one week following the procedure.
Take it easy! Avoid lifting anything heavier than a gallon of milk for the first 24 hours. Strenous exercise of the arm on the same side as the biopsy should be limited during this time to allow for healing.
You many return to work after the procedure if your work does not interfere with the biopsy after-care instructions. That said many people plan to take the rest of the day off from work to rest. Please let your technologist know if you need a work excuse for the procedure.
There are no diet restrictions following the procedure.
Leave the vinyl dressing and Steri-strip bandage on for the first 24-48 hours after your procedure. If it begins to come off, you may replace it with a clean dressing or bandage. While the Steri-strips remain in place, apply antibiotic ointment such as Neosporin or Bacitracin with bandage changes.
Wearing a sports bra for added support may be most comfortable.
Watch for signs of concern such as bleeding or infection. When you leave the clinic, you will not be bleeding. If bleeding occurs after your leave the clinic, apply firm pressure with both hands to the site for at least10 minutes or until the bleeding stops. If the site continues to bleed, seek medical attention. Some redness at the biopsy site is normal, but if swelling and drainage at the site increase in the week following biopsy, that may be a sign of infection. this is especially true if your also have a fever.
Your results
You can typically expect to receive the results from your biopsy in 1-3 business days. Sometimes the results may take longer if additional testing is needed for the most accurate result. You will have an opportunity to discuss your results and the recommendations for next steps with a member of your healthcare team at GRACE. You and your primary care clinician will also receive written copies of the results.
When the pathology results come in, the radiologist will review the results and determine if the pathology results are concordant or discordant with the imaging findings. If the pathology results are concordant, that means it is reasonable that what is seen under the microscope by the pathologist can cause the imaging finding that led to biopsy. A discordant pathology result means that it would be unusual for the changes under the microscope to be the cause of the type of changes seen on imaging. A discordant result raises the possibility that the small tissue samples taken did not give a true look at the whole process.
Breast biopsies are extremely accurate and are considered the gold-standard for evaluating concerning breast tissue. However, around 3-4% of the time, the breast biopsy result may not explain the worrisome imaging appearance. If this happens the biopsy result from the pathologist is called discordant with the imaging result from the radiologist. When the biopsy results are discordant, your radiologist will often recommend surgical excision of the concerning area so that the pathologist can look at every part of the tissue under the microscope instead of just a small sample.
Other considerations
Although hearing that you may need a biopsy can be concerning and worrisome, keep in mind that biopsy is an integral part of breast cancer screening and it can lead to earlier diagnosis of breast cancers. Smaller breast cancers are more easily treated and most biopsies show non-cancerous results. A core biopsy is a good way to get definitive answers when there are concerns about your breast health.
At GRACE, you are our priority. We aim to provide you with a complete understanding of your breast health by ensuring quality imaging, open communication and trust. Our dedicated staff and fellowship trained radiologists are exceptionally experienced in every facet of breast imaging including image guided procedures. You are in good hands at GRACE.