Breast Biopsy Basics

Finding a lump in your breast or being told that a breast cancer screening found something suspicious can be terrifying. The next step is to have a breast biopsy to find out whether it is benign (non-cancerous) or malignant (cancerous). Moffitt’s Dr. Robert Weinfurtner and Dr. John Kiluk break down breast biopsy basics and offer the following advice.

What is a biopsy?
A breast biopsy is a procedure in which a needle is inserted into the breast to collect a sample of a suspicious lesion that came up on a breast cancer screening.  At Moffitt, doctors make a very small nick in the skin with a scalpel to allow physicians to more readily place the needle into the breast. Afterward the skin nick is closed with medical glue, which may leave a minimal scar. The biopsy sample is sent to a team of skilled pathologists for an in-depth review. 

Will it hurt?
The breast biopsy procedure is designed to minimize patient pain and discomfort.  Local anesthesia (numbing medication) is given with a small needle before the biopsy in the skin and along the tract to and around the lesion. This can feel like a pinching or burning sensation for a few seconds until the numbing medication starts working.  After that, the patient may feel pressure during the procedure but should not feel pain.  The area of biopsy should be completely numb when the biopsy begins.

Blood-thinning medications, such as aspirin, should not be taken for a week prior to a biopsy because they can lengthen the time it takes for blood to clot. This increases the risk for a large hematoma (a collection of blood or internal bruise) from the procedure.  When this occurs, the bruise can last weeks and cause discomfort to the patient until it resorbs.  Thus, these medications are typically stopped a week before a breast biopsy, unless the clinician feels that the risk from stopping the medication is too high.  In those cases, the risks are discussed with the patient and doctor to determine the best plan for biopsy. 

Immediately after breast biopsy, the patient will still be numb but may feel a little soreness. This may increase over the next few hours as the numbing medication wears off.  Ice packs and acetaminophen (Tylenol) can help reduce the soreness. Dr. Weinfurtner recommends no heavy lifting, which is anything greater than two pounds with the same side arm and no repetitive motions with the arm (sweeping, tennis, etc.) for the next two days.  After two days, the patient can expect to ease back into normal activity. 

Will I be lying down?
It depends. During a biopsy, radiologic guidance (mammographic, sonographic (ultrasound) or MRI), is used to guide the needle to the lesion in question. Each method requires the patient to position themselves differently.

• Ultrasound Guided Procedures - Patients lie on their backs with the arms resting over their heads.
• Mammographically-guided procedures (stereotactic biopsies) - Patients lie stomach down on the prone table, which has a hole in the table for the breast. At Moffitt, due to the convenience and comfort of the upright chair, as well as the highly efficient biopsy mode, most mammographically-guided biopsies are performed in the upright chair as are newer tomosynthesis-guided biopsies. 
• MRI-guided biopsies - Patients lie on their stomach on the MRI table and the breast will rest through a hole in the table.  This allows gravity to help elongate the breast for efficient targeting. 

In some cases, an excisional biopsy where a portion of the breast is removed is necessary. This is done by a surgeon.  In cases where the biopsy resulted in a large bruise, the discomfort may last longer and sometimes many weeks.  This happens in only a small minority of cases; however, most patients resume normal activity in a few days.

What types of biopsies are there?

• Fine needle aspiration biopsy - Fine needle biopsies yield less tissue for evaluation by the pathologist than core needle biopsies.  The advantage they offer is they can biopsy some lesions that are otherwise difficult to biopsy with a larger core needle.  At Moffitt, fine-needle aspiration is routinely performed for axillary (armpit) lymph node biopsies.  For these, the pathologist is available to evaluate the samples in real time to determine when enough lymph node cells are present to fully evaluate later, after appropriate pathology preparation and staining.   
• Core needle biopsy - Core needle biopsy yields a cylinder (core) of tissue each time a biopsy is taken.  For spring-loaded biopsy devices, the needle is inserted into the target and removed during each biopsy (typically 3-5 biopsy cores are taken).  For vacuum-assisted core needle biopsies, the needle is inserted into the target and biopsies are taken by turning the needle and stopping at intervals around 360 degrees.  This is typically faster than spring-loaded core biopsy and yields larger cores.  At Moffitt, we use spring-loaded devices when we can be precise with the real-time imaging of ultrasound, and we use vacuum-assisted core needle devices when we are not seeing real-time (i.e. during stereotactic or MRI biopsies).
• Stereotactic biopsy - Stereotactic biopsies are performed when the lesion is seen mammographically and not definitively seen with ultrasound.  Calcifications are the most common stereotactic biopsy target, as these are not well seen with ultrasound.
• Ultrasound-guided core needle biopsy - Ultrasound-guided core needle biopsy is the most common type of biopsy, performed on any suspicious lesion identified with ultrasound.  This biopsy method is preferred, as the patient is able to lie comfortably on their back, does not have to lie perfectly still (as with stereotactic and MRI biopsies) and ultrasound does not use radiation.
• MRI-guided core needle biopsy - MRI-guided biopsy is the most complex type of biopsy we perform.  This is reserved for suspicious enhancing lesions that are only identified by MRI.  MRI is the most sensitive modality for detecting breast cancer, so a number of cancers are only seen with MRI.
• Surgical biopsy - Surgical biopsy is a last-resort type of biopsy.  This is performed when a core-needle biopsy cannot be performed (eg. when calcifications cannot be safely biopsied stereotactically due to close proximity to the chest wall or to a breast implant) or was inconclusive (certain types of pathology, termed “high-risk” require additional tissue to make a definitive diagnosis).  Core needle biopsy is preferred, if feasible, to surgical biopsy because the surgeon prefers to know the pathology before surgery for appropriate surgical planning.  Core needle biopsy also removes less tissue and does not cause as much deformity as surgical biopsy.

When will I get my results?
At Moffitt, results are typically available in 3-5 business days.