breast cancer first develops it is common that there are no symptoms of this
disease at all. There is no pain associated with the early stages of breast
If any of the below
changes occur, you should see the doctor immediately. More than likely you will
be asked to have a thorough examination, mammogram and or an ultrasound to help
diagnosis what this change might be.
Being pro-active with doing breast exams monthly
is of utmost importance. Especially, if there is any family history of breast
cancer. If you detect any abnormality, a mammogram and a physical exam will be
ordered. If there is any concern with either of those exams, then an
ultrasound will be performed on your breast.
To find out the cause of any unusual signs or
symptoms in a woman’s breast, a physician will do a careful physical exam along
with asking about personal and family medical history.
The doctor may do one or more of the breast
exams described below:
physician can tell a lot about a lump with its size, texture and whether or
not it moves easily. Palpation includes feeling the lump and surrounding
tissue around it. Benign lumps feel significantly different from cancerous
– this is an x-ray of the breast, which gives the radiologist information
about the breast lump. If an area on the mammogram looks abnormal, then
additional x-rays are usually needed.
– this is high frequency sound waves. This test shows whether or not a lump
is solid or filled with fluid. Ultrasonography is used along with a
mammogram when diagnosing a suspicious area.
Imaging tests for diagnosing an abnormal mammogram or a lump:
Depending on the results of the imaging test,
the patient will be referred for a breast biopsy. A Breast Biopsy is the only
definitive way to determine whether cancer is present. Based on the
examination of the patient, mammogram and ultrasound test a physician may decide
to have a needle aspiration or biopsy performed. With this test fluid and or
tissue is removed from the breast to make a diagnosis.
Doctors determine what method of biopsy based on the
The shape of the lump
The size of the lump
The location of the
The number of
The training of the
radiologist or surgeon who is performing the biopsy
The breast imaging
center or surgical center
Risks and side effects of a breast biopsy differ on the type of biopsy that is
necessary. Patients should talk with their physician prior to undergoing the
procedure about the advantages and disadvantages of each different biopsy
The procedure for a needle biopsy or a fine
needle biopsy uses a fine gauge needle (22 or 25 gauge) and a syringe to sample
fluid from a breast cyst or remove clusters of cells from a solid mass.
If a breast lump is felt, the radiologist or
surgeon will guide a needle into the area of concern by palpating the lump. If
the lump cannot be felt, the FNA procedure will be done with the assistance of
either stereo-tactic mammography or
ultrasound with the patient in either in
the upright or prone position.
Aspiration or Needle Biopsy will remove the
fluid or a small amount of tissue from the actual breast lump. This
procedure will determine whether a lump is a fluid filled cyst (not cancer) or a
solid mass (which may or may not be cancer). The tissue is removed with a needle
from an area that is suspicious on a
After the needle is inserted into the breast
where the abnormality is, a vacuum is created and multiple needle motions are
performed. This is done to ensure that adequate tissue is taken for diagnosis
at the laboratory.
If tissue is removed in a needle biopsy then the
physician or radiologist will want a pathology done on this at a laboratory. If
fluid is removed from a cyst, then the fluid may or may not be checked by a
This procedure is done as an outpatient basis.
Fine Needle Aspiration does not require stitches, and a small bandage is placed
over the area after the procedure. Fine needle aspiration is the fastest method
of breast biopsy with the result available rapidly. This procedure is great for
confirming breast cysts.
A core needle biopsy involves removing small
samples of breast tissue using a hollow “core” needle. For lumps that are able
to be felt, the radiologist fixes the abnormality in one hand and performs a
needle biopsy with the other. With lumps that are not palpable and cannot be
felt, stero-tactic mammography and ultrasound image is used to help determine
the exact location of the breast mass based on mammograms taken from two
The needle used in a core needle biopsy is a
larger gauge than the one that is used for a fine needle biopsy. Normally a 16,
14, or 11 gauge needle is used. This core needle biopsy needle also has a
special cutting edge attached to it.
Core Needle Instruments
Lidocaine is used to help numb the area. Anywhere from three to six separate
needle insertions are needed to obtain a sufficient sample of breast tissue. Slight pressure is felt during the core needle biopsy. As the tissue is being
retrieved, a clicking noise can be heard from the needle and sampling
instrument. The average sample size that is retrieved is approximately 2.0 cm.
long and 0.16 cm. in diameter is removed. The samples are then sent to
pathology for diagnosis.
Vacuum Assisted Biopsy is a new way of
performing breast biopsies. The trade name for this procedure is called a
Mammotome or a MIBB. This procedure relies on stereo-tactic
mammography and or ultrasound imaging to pinpoint the exact location of the
abnormality. The vacuum assisted biopsy procedure is done
with the assistance of either stereo-tactic mammography or ultrasound
with the patient in either in the upright or prone position.
Image courtesy of
Vacuum Assisted Biopsy or Mammotome
This is a minimally invasive procedure that
allows for the removal of multiple tissue samples. Compared to the core needle
biopsy which uses multiple needle insertions to acquire one sample the vacuum
assisted biopsy is a unique device only needs to be inserted once into the
breast through a small area in the skin of the patient’s breast. If the
radiologist needs to examine other areas of the breast, then the probe is
rotated moving the sampling chamber 30 degrees to the new position. This entire
cycle is repeated until all desired areas have been sampled (which is normally
between 8 – 10 samples of breast tissue around the abnormal lump).
The vacuum line draws the breast tissue through
the probe of the device into its sampling chamber. Once the tissue is in the
sampling chamber, the rotating cutting device is advanced and a tissue sample is
captured. If the patient has more than one abnormality, then in some cases a
small sterile clip is placed into the biopsy site of the breast to mark the
location in case if a future biopsy is needed. The tiny clip is a “micro-clip”
and is left inside the breast and causes no pain or harm to the patient. The
samples are then sent to pathology for diagnosis.
Vacuum-assisted breast biopsy is being more
commonly used however; requires a highly skilled radiologist or surgeon to
perform the procedure.
Patients will experience some swelling and
bruising after the procedure and are instructed to take over the counter pain
relief if needed (Tylenol). Bruising occurs during the first five to seven days
after the biopsy. Bruising is temporary and normal after a biopsy.
ADVANTAGES OF VACUUM ASSISTED BIOPSY VS. OPEN
Vacuum assisted biopsies (VAB) are minimally
invasive using only .25 inch of an incision site – versus a surgical biopsy
that require at least 1.5 to 2 inches for an incision.
VAB has little to no scarring - versus a
surgical biopsy that might leave a significant scar.
VAB is performed under local anesthesia
versus a surgical biopsy that might require either local or general
VAB requires no stitches versus a surgical
biopsy which does require stitches.
VAB is performed in less than hour versus
surgical biopsy which can take an hour or more.
VAB all patients can return to activity
immediately versus surgical biopsy which needs a day to recover.
VAB cost significantly less than a surgical
VAB usually provides a definitive diagnosis
with the tissue samples collected. Surgical biopsy does give a definitive
diagnosis with the tissue samples.
A large core breast biopsy or Advanced Breast
Biopsy Instrumentation; is a surgical technique that involves removing the
entire intact breast lump or abnormality under the help of using stereo-tactic
mammogram. This method of breast biopsy tends to be less invasive than a
traditional open surgical biopsy, but has not gained widespread acceptance
because of the controversy of taking a significant portion of normal breast
tissue just to reach the abnormality. With surgical biopsy, the surgeon will
only remove a narrow small strand of breast tissue in order to reach the
Lidocaine is used to numb the breast. A wire is
then guided into the breast abnormality using stereo-tactic mammography. A
cannula or the large core needle is then inserted into the breast using the wire
as a guide. The core specimen is removed using a looped wire and then the
tissue is sent to pathology.
Large Core Biopsy Large Core Biopsy with Wire Localization
Critics of this procedure claim that large core
biopsy does not take an adequate amount of tissue around the breast abnormality
for the laboratory to analyze; however it removes unnecessary normal breast
tissue. Large core biopsy can remove 5 mm to 20 mm of breast tissue. The
procedure also allows the radiologist or surgeon to remove the entire lesion in
one non-fragmented piece. However, some medical professionals question the
benefit of this.
Due to the large size of the biopsy section,
sutures are required. Also, the procedure takes one hour and is followed by
several hours of recovery.
Traditional open surgical biopsy is still considered the “gold standard” to
other methods of breast biopsies. Surgical biopsy uses a 1.5 to 2.0 inch
incision in the breast. Because of the advancement in technology, there are
less invasive biopsy procedures available now such as the Core Needle Biopsy or
the Vacuum Assisted Biopsy.
During an “excisional surgical biopsy” procedure, the surgeon will try to
completely remove the area of concern (abnormality), often along with a
surrounding margin of normal breast tissue. If the lump is palpable, it is
excised in an uncomplicated surgery which is performed in an operating room.
During an “incisional surgical biopsy”, the surgeon will only remove the part of
the breast abnormality. The incisional surgical approach is only performed on
Sometimes the surgeon will use
mammography to help locate the area of the
abnormality and mark the area with a wire marker, dye, carbon particles or
several of these methods. This is commonly referred to as needle or wire
localization and is necessary when the abnormality can only be seen on imaging
tests. Wire or needle localization is only performed on the abnormalities that
cannot be felt. A thin wire is put through the center of the hollow needle to
indicate the exact area of removal. There is a hook at the end so the wire will
not slip off from the soft breast tissue. The needle is removed, with the wire
in place. The radiologist will then perform a second mammogram to ensure the
position of the wire is in the correct area of the breast.
inside the operating room the surgeon will remove the wire and the surrounding
margin of breast tissue. A set of x-rays are taken of the removed specimen with
the wire. Another set of x-rays are taken of the breast to confirm the area in
question was in fact removed. Once this is finished, the specimen is sent to
pathology for a diagnosis.
incision is closed with suture material. The surgeon will either use
dissolvable sutures or permanent sutures. If dissolvable sutures are used, the
sutures material will absorb and dissolve in the body on their own within 60-90
days. There is no need for removal with dissolvable sutures. If permanent
sutures are used, then the patient needs to have these removed within a week.
The scar from a surgical biopsy is normally small.
Open surgical biopsy can possibly alter the shape of a woman’s breast on the
The size of the breast
The location of the
The amount of
surrounding breast tissue that is removed in addition to the abnormal lump
ADVANTAGE OF OPEN SURGICAL INCISION BIOPSY
surgical biopsy excises the largest breast tissue sample compared to all the
other breast biopsy methods. The accuracy of the diagnosis using the open
surgical method is close to 100%, making it the “gold standard” of breast biopsy
the diagnosis is cancer, the pathologist will be able to tell what kind of
cancer it is. Breast cancer either starts out in a duct or a lobule. The
pathologist will also be able to tell whether the cancer is invasive and if it
has in fact invaded nearby tissues of the breast of lymph system. If a
spot is detected in the lymph nodes, a biopsy of this area will be done as well.
Hormone receptor tests are done to see if the cancer is estrogen and
progesterone receptor positive. If the results are positive for these
hormones, it means that these actual hormones contribute to the cancer growth
and more than likely will respond to hormonal therapy. Other lab tests are done
to see if the cancer is likely to grow slowly or quickly.