Editing Breast biopsy techniques


== FNA ==

* Technique
** 21-23-gauge needle, 10mL syringe, USS
** Clean skin, fix the lump between thumb and forefinger, and put the needle tip into the lesion
** Generate negative pressure and move the tip back and forth within the lesion
** Remove the needle
** Make a smear of aspirate on the glass slide and spray it with a fixative
* Does not differentiate non-invasive lesions from invasive, if malignant cells are identified
* Can have a role in proving multi-focal malignancy, if the first lesion is already known
* Also useful for evaluating lymph nodes positive on examination or imaging (sensitivity 90%, specificity nearly 100%). May need to place a clip at time of biopsy.
* Needs to contain breast epithelial cells to be diagnostic in most cases

== Core biopsy ==

* Preferred method for sampling breast lesions
** Allows examination of tissue architecture (differentiation between DCIS and carcinoma)
** Allows immunohistochemistry
* Perform under USS, stereotactic, or MRI guidance (use the easiest method available for that lesion)
** USS is best for mass lesions and generally easiest
** Stereotactic is best for calcifications and densities seen on mammogram, but is very uncomfortable (see below)
* Technique
** Infiltrate LA to skin, but no deeper
** Make a small nick with a number 11 blade
** Fix the lump between thumb and forefinger
** Penetrate the lump with core needle biopsy (8-14 gauge)
** Warn about clicking sound and fire
** Obtain at least 3 samples from each lesion, and transfer the samples to formalin bottles (if it's a good specimen, it will usually settle within the formalin)
** Clip should be placed and specimens should be imaged to confirm that the targeted lesion has been adequately sampled
* Failed biopsy is an indication for localisation and surgical excision

== Punch biopsy ==

* Indications
** Paget's disease
** Inflammatory breast cancer
* Technique
** Clean and apply LA
** Use a 4mm punch, use scissors to separate from fat
** Send in formalin
** Pressure/steristrip/suture

== Excisional biopsy ==

* Indications:
** Imaging findings and pathologic findings do not correlate
** Atypical ductal hyperplasia
** Atypical lobular hyperplasia
** Radical scar, complex sclerosing lesion
** Papillary lesions
** Cellular fibroepithelial lesions and Phyllodes tumours
** LCIS
** Mucocoele-like lesions
* Technique
** Localisation - can discuss with radiologist
*** Hookwire
*** Radioactive seed localisation
*** Intra-operative USS
*** Fluoroscopy (to find the clip)
** Excision
*** Plan the incision as for WLE
*** Raise a skin flap between incision and wire, then grasp the wire with artery forceps
*** Follow the wire using diathermy
*** When you get to the last 2cm of the wire, excise the lesion, marking it with sutures and send it for x-ray
*** Haemostasis
*** Check x-ray +/- re-excise margins
*** Close in layers
* Follow-up after excision biopsy
** Patients with benign findings should have a new baseline mammogram 4-6 months post biopsy

== Stereotactic biopsy ==

* False negative rate of 11.8-28.6%
* Risk of bleeding, haematoma or infection is less than 1%
* Indications
** BI-RADS 4 + 5 require biopsy, BI-RADS 3 is at clinician/patient discretion (according to Kat mostly recommend follow-up with yearly mammogram)
** New suspicious microcalcifications, developing asymmetries, or architectural distortions
** Nonpalpable asymmetry, focal asymmetry, or solid mass on mammogram not seen on USS
** Mammographic lesions corresponding to suspicious areas of enhancement on MRI
* Contraindications
** Patient unable to lie prone or co-operate
** Weight
** Lesion location near nipple, too superficial to skin, or too posterior to chest wall
** Lesion mammographically occult
** Patient has severe kyphosis or movement disorders
** Lack of breast tissue thickness for adequate compression
** Pregnancy
* Pathologic correlation
** Need concordance with prior imaging reports
** X-ray specimens to see whether recorded calcifications were gathered - if not, quality of biopsy is suspect
* Target of biopsy
** Aim for five flecks of calcification, or flecks in three separate cores

[[Category:Breast]]