Biopsies:

A biopsy involves removal of tissue to be studied under a microscope in order to determine a diagnosis. Biopsies can range from a tiny amount of tissue to large amounts of tissue; for example, a fine needle aspiration involves the removal of a small amount of cells while an excisional biopsy involves removing the entire piece of abnormal tissue. Biopsies can be performed whenever an abnormality in the breast can be felt. A biopsy can also be performed using image guidance when the abnormality can only be seen on mammogram, ultrasound or MRI.

Fine Needle Aspiration

A Fine Needle Aspiration (FNA) is performed by inserting a small needle into the breast through the skin and collecting a sample of cells. The groups of cells are collected (aspirated) into the needle are then smeared onto a microscope slide and sprayed to preserve the cells for analysis by a cytologist. This can be a very accurate way of detecting the presence of cancer cells and results are available usually within 24 hours.

Needle Core Biopsy

A Needle Core Biopsy removes a larger amount of tissue, and can be more useful for understanding treatment options prior to surgery when the cells prove to be cancerous. With this procedure a small amount of local anesthetic is injected into the skin of the breast and a tiny nick is made with a scalpel (no stitches are required because the incision is so small). A larger needle is then placed into the breast lump and tiny slivers of tissue are removed in a few seconds. This material is examined under the microscope by a pathologist. The results are usually available in 24 to 48 hours.

Image-Guided Breast Biopsy

Both stereotactic and ultrasound guided biopsies can be very accurate; the choice of guiding technique depends on where an abnormality is located and how it is best seen. If an abnormality is better seen on a mammogram, then often stereotactic guidance is preferred; if better seen by ultrasound, then ultrasound guided breast biopsy might be a better option. Hartford Hospital also now offers MR-guided breast biopsy for women who have abnormalities identified only by MRI scans.

Image-Guided Breast Biopsy Results

A pathologist will evaluate the biopsy. This usually takes a few days to complete. Most biopsies turn out to be benign and need nothing else done. If a more serious result is found, the woman's doctor will be able to discuss appropriate follow-up arrangements with her.

Below a very magnified X-ray of two specimens from a stereotactic Mammotome breast biopsy. The tiny white dots are specks of calcium, which confirm the area of concern was successfully sampled with the biopsy. These samples are actually about the thickness of a strand of spaghetti.

Image-Guided Breast Biopsy History

Hartford Hospital is a leader in image guided breast biopsy, using stereotactic and ultrasound techniques. Stereotactic breast biopsy was introduced at Hartford Hospital in 1988. After a pilot study to validate the technique, it was offered as a clinical service in 1991. In 1993, one of the first LORAD stereotactic prone breast biopsy tables was put into service and digital imaging technology soon was developed for it; this remains the state of the art standard today. Hartford Hospital was among the first facilities in America to offer the Mammotome biopsy system and now this system is available for both stereotactic and ultrasound guided biopsies. The Suros ATEC system is also now available at Hartford Hospital as well. This allows the radiologist to use the most appropriate device for every woman's biopsy procedure.

Hartford Hospital is the first facility in central Connecticut to offer MRI guided breast biopsy. This procedure was a natural evolution of our clinical service coming after five years experience with MRI guided breast needle localization.

Ultrasound Guided Biopsy

When using ultrasound, an abnormality is identified and the biopsy device is directed to the abnormality (lesion) by watching it on the ultrasound display. Usually several core samples are obtained and sent to the pathologist for evaluation. A marker clip may be left to identify the site of the biopsy for future reference.

Stereotactic Biopsy

Patients having a stereotactic biopsy will lie down on the stereotactic table. The breast will enter a hole in the center of the table and will be placed in compression by the digital mammography unit under the tabletop. This allows for accurate targeting by immobilizing the breast. After injection of a local anesthetic and verifying targeting, stereotactic images will confirm accurate needle placement and the biopsy may then continue. An average of 6 specimens are taken during a typical biopsy. If the abnormality contains calcifications, then an X-ray of the specimen can confirm the accurate targeting and retrieval of the calcifications. A marker clip may also be placed after the stereotactic biopsy.

MRI Guided Breast Biopsy

An MRI guided biopsy is performed in much the same manner as a routine breast MRI exam. A grid is applied to the surface of the breast to accurately identify the location of the abnormality. After injection of a local anesthetic, biopsy is then performed with a core biopsy device similar to the one used for stereotactic biopsy. Usually a marker clip is placed after the biopsy to aid in future identification of the area biopsied.

Skin Punch Biopsy

If there is an abnormality noted in the skin, whether it is redness or thickening of the skin, a punch biopsy may be performed. Local anesthesia is given and then, with a tiny needle, a small sample (called a punch) of skin is taken that may be as tiny as an eighth of an inch. This will leave a very tiny hole in the skin. A bandage will be placed on the area and a small scab will form. This will heal with a minimal scar. This biopsy result will be available within 48 hours.

Needle Localization Excision

A Needle Localization Excision is an example of an open surgical biopsy meaning that it is performed in an operating room under local anesthesia and sedation. This technique is necessary only when the abnormality is seen by MRI, ultrasound or mammography and is not able to be felt. In this situation a mammogram, ultrasound or MRI is used to identify exactly where the abnormality exists. A local anesthesia is administered to numb the skin and a very fine wire is then placed through the skin to the abnormality. This very fine wire acts as an arrow for the surgeon. The wire, where it exits the skin, is then covered with a dressing and the patient is transferred to the preoperative area. An anesthesiologist then interviews the patient. After that, the patient is brought to the operating room where a local anesthesia with sedation is administered. Once the patient is sedated, an incision is made. Using the wire as a guide, the surgeon is able to remove the presumed abnormal tissue (commonly called excise). The wound is closed with sutures and a bandage is placed over the incision. These biopsy results are usually available within 48 hours. MRI is not often used for this procedure; Hartford Hospital is one of the few institutions in the country that allows the use of MRI guidance in needle localization.

Lumpectomy

Lumpectomy is also an example of an open surgical biopsy. This procedure is used when there is a lump that can be felt, and is performed in the operating room. After the patient is given local anesthesia with sedation, an incision is made, and the lump is removed (excised) along with a very small amount of normal tissue that surrounds the abnormal area. The tissue is then sent to the laboratory for an analysis by the pathologist. This incision is closed with absorbable stitches and covered with a gauze dressing. These results are available within 48 hours.

Breast Biopsy Marker Clip

Marker clips used for breast biopsies are made of titanium or surgical stainless steel and are about 2 millimeters in size. When the radiologist or surgeon feels a marker should be used, they are inserted at the end of breast core or needle biopsy procedures to mark the site of the biopsy for later reference. This is an important step to take since most abnormalities biopsied are small or subtle and can become extremely difficult or impossible to identify after a core biopsy procedure.

When a biopsy result is abnormal and an excision or lumpectomy is necessary, the marker clip allows accurate localization of the abnormal site for removal so that as little tissue as necessary is removed while optimizing the chance of clear margins.

Most patients have normal (benign) results from these types of biopsy, however the presence of the marker is very reassuring when seen on follow-up mammograms; it shows exactly where the area was biopsied. This avoids confusion in interpretation of follow-up mammograms and can prevent the need for future biopsies in that same area.

The marker is safe; sensitivity to the material is very rare. In general women cannot feel the clip. They do not set off airport detectors and do not cause interference problems in MRI.