At some point in your life, you may have a lump or change in your breast or an abnormal finding on a mammogram. To make sure it is not cancer, you will have follow-up tests.
Learn more about follow-up after an abnormal mammogram or clinical breast exam.
In many cases, breast cancer can be ruled out with a diagnostic mammogram, breast ultrasound or breast MRI. However, if cancer can't be ruled out, you will need to have a biopsy.
A biopsy involves removing cells or tissue from the suspicious area of the breast. The cells or tissue are studied under a microscope to see if they show cancer.
If you need to have a biopsy, don’t panic. Having a biopsy can be scary, but keep in mind that most breast biopsies in the U.S. do not show cancer . Still, a biopsy is needed to know if something is cancer or not.
If breast cancer is found, it can be treated. When breast cancer is found early, the chances for survival are highest. Learn more about breast cancer treatment.
There are two main types of biopsies used to diagnose breast cancer:
A needle biopsy uses a hollow needle to remove samples of tissue or cells from the breast. A pathologist studies these samples under a microscope to see if they contain cancer. If they do, more tests will be done to help you and your health care provider plan your treatment.
Needle biopsies can be used to study a:
There are two types of needle biopsies:
Core needle biopsy uses a hollow needle to remove samples of tissue from the breast. It can be used to biopsy a:
Core needle biopsy is often the preferred biopsy method because it is accurate and does not involve surgery.
If a lump can be felt, a core needle biopsy can be done in a health care provider's office.
Before the procedure begins, the provider will use a small amount of local anesthetic to numb the skin and breast tissue around the suspicious area. He/she will then insert the needle and remove a small amount of tissue.
For a nonpalpable mass, a core needle biopsy is slightly more involved. It will likely be done in a clinic or imaging center.
The health care provider will locate the abnormal area with the help of ultrasound or a special type of three-dimensional mammography, called stereotactic mammography. The accuracy is similar using either types of imaging .
During a needle biopsy with stereotactic mammography, you lie on your stomach on a special table and your breast fits through a hole in the table (see Figure 4.2).
Before the procedure, the health care provider will use a local anesthetic to numb the area. Your breast will be compressed like it is for a mammogram, and several images will be taken. These images help the provider guide the biopsy device to the suspicious area in the breast. A needle in the device removes tissue samples. In some centers, the needle removes tissue with a vacuum assisted probe. The needle is inserted and removed quickly. You may feel a pushing and pulling sensation on your breast, which can cause some discomfort.
During a core needle biopsy with ultrasound, you lie on your back. Before the biopsy procedure, the provider will use a local anesthetic to numb the area.
The health care provider holds the ultrasound device against your breast to see the area. The ultrasound image helps the provider guide the needle as it enters the breast and reaches the abnormal area. The provider then removes a sample of tissue with the needle. In some centers, this is done with a vacuum assisted device. The needle is inserted and removed quickly. You may feel a pushing and pulling sensation on your breast, which can cause some discomfort.
Core needle biopsy is accurate when done by an experienced radiologist. It is quick and does not involve surgery. There is only a small chance of infection or bruising.
If breast cancer is found, the tissue removed during a core needle biopsy gives important information including:
Learn more about these tumor characteristics.
This information helps you and your health care provider plan your treatment.
If the tissue sample is benign (not cancerous), surgery may be avoided. In some cases, however, even if the tissue sample is benign, an excisional biopsy (a surgical biopsy) may be needed to confirm the diagnosis.
One drawback of core needle biopsy is that the needle can miss a tumor and take a sample of normal tissue instead. This is most likely to occur when the biopsy is done without the help of stereotactic mammography or ultrasound.
If a tumor is missed, the biopsy will show cancer does not exist when in fact, it does. This is called a false negative result and can delay diagnosis. For nonpalpable masses, false negative results occur in up to eight percent of stereotactic mammography- or ultrasound-guided core needle biopsies . For palpable masses, false negative results are more rare .
Another drawback of core needle biopsy is that it may not give full information about the tumor. For example, it can't tell the size of a tumor and sometimes, it can't tell whether a tumor is ductal carcinoma in situ or invasive breast cancer. Taking multiple tissue samples can help limit this problem. However, in some cases, a surgical biopsy is needed to get complete information on the tumor.
Fine needle aspiration (also known as fine needle biopsy) removes cells from a suspicious lump in the breast. The needle used is thinner than in core needle biopsy.
Fine needle aspiration is only used for lumps that can be felt (palpable masses). Although core needle biopsy is most often the first choice for palpable masses, fine needle aspiration is sometimes done as a quick way to sample a breast lump felt during a clinical breast exam.
A fine needle aspiration can be done in your health care provider's office. Before the procedure, your provider may use a small amount of local anesthetic to numb the area. He/she will then insert the needle and remove a sample of cells. The whole procedure only takes a few minutes.
Fine needle aspiration is accurate when done by an experienced provider and read by an experienced cytopathologist (a physician who specializes in checking cells under a microscope).
The procedure is less uncomfortable than a core needle biopsy and the chance of infection or bruising is very small.
If the lump was not thought to be cancer before the fine needle aspiration, a benign (not cancer) test result means you will likely not need a surgical biopsy.
One drawback of fine needle aspiration is that the needle can miss a tumor and take a sample of normal cells instead. If this happens, the biopsy will show cancer does not exist when in fact, it does. This is called a false negative result and can delay diagnosis. When combined with a clinical breast exam and a mammogram, the false negative rate of fine needle aspirations of lumps that can be felt is about five percent .
Sometimes, even if the correct area is sampled, the procedure may not remove enough cells to be able to tell if they contain cancer. So, a fine needle aspiration that does not find cancer may need to be followed up with a core needle biopsy or a surgical biopsy.
Another drawback of fine needle aspiration is that the cell samples give limited information about the tumor. For example, they often cannot tell whether a tumor is ductal carcinoma in situ or invasive breast cancer. The cells removed by fine needle aspiration must also be checked by an experienced breast cytopathologist, and not all hospitals have a cytopathologist.
Your provider will determine which type of biopsy is the best way to rule out or confirm breast cancer. Most often, a needle biopsy is done first (then, if needed, a surgical biopsy is done).
Learn more about the advantages and drawbacks of each type of biopsy in Figure 4.1.
Figure 4.1:Risks and Benefits of Needle Biopsy versus Surgical Biopsy
A surgical biopsy is the most accurate way to
diagnose breast cancer and get complete information about the tumor.
However, it is more invasive than a needle biopsy. Because core needle biopsy is accurate in diagnosing cancer and does not involve surgery, it is often the preferred biopsy method [3,5].
In most surgical biopsies, the entire
suspicious area plus some of the surrounding normal tissue is removed
from the breast (excisional biopsy). In certain cases, when the entire
area is too large to remove, only part of it is taken out (incisional
Some people need an excisional biopsy instead of a needle biopsy.
With excisional biopsy, the whole abnormal area (plus some of the surrounding normal tissue) is removed.
A surgeon performs the procedure in an operating room. He/she will use local anesthetic to numb the area that will be biopsied and you will also get IV sedation (rather than general anesthesia). You probably won't need to stay overnight in the hospital.
Before surgery, a wire-localization or needle-localization procedure may be done. During this procedure, a radiologist uses a mammogram or ultrasound image to guide a very thin wire into the suspicious area of the breast. The surgeon then uses this wire to find the area during surgery.
The breast tissue that is removed is usually X-rayed. This lets the surgeon and radiologist match the suspicious areas on the mammogram with those in the biopsy tissue. If the areas match, the correct tissue was removed. If the areas do not match, the surgeon may try again to remove the correct tissue or may wait to do another biopsy.
Although the goal of an excisional biopsy is to diagnose cancer, sometimes the surgeon may be able to fully remove the cancer. In these cases, excisional biopsy may be the only breast surgery needed to treat the cancer. For others, lymph nodes may also need to be removed in a second surgery at a later date.
Learn more about breast cancer treatment.
If the biopsy shows cancer, a pathologist will study all the tissue removed during surgery to determine whether there is a wide enough rim of normal tissue surrounding the tumor. This rim (called a margin) helps show whether or not all of the tumor was removed.
Clean (also called "uninvolved", "negative" or "clear") margins mean there is a wide enough rim of normal tissue surrounding the tumor. In most cases, when margins are clean, no further surgery is needed.
Positive (also called “involved”) margins mean there are cancer cells in the tissue surrounding the tumor, and more surgery is needed to get clean margins. More surgery may also be done when the tumor margins are not wide enough.
The tissue sample is sent to a pathologist. The pathologist preserves the sample and then studies it under a microscope. Learn more about pathology exams.
In the U.S., the standard way to preserve a tissue sample is called formalin fixed paraffin embedded tissue. The sample is treated with a substance called formalin, which hardens the tissue and prevents it from breaking down over time. Then, the sample is embedded in a block of paraffin (wax).
In some cases, part of the biopsy sample is frozen in the pathology lab during a surgical biopsy. The pathologist examines thin sections of this frozen sample under a microscope to check for cancer cells or to assess the margins (see how close the cancer cells are to the edges of the sample).
Although a frozen section can give a quick check of the tissue sample, it may be linked to false negative or false positive results . A false negative result suggests cancer is not present when in fact, it is. A false positive result suggests cancer is present when it is not. For this reason, the results from a frozen sample always need to be confirmed by other methods, which can take several days.
Surgical biopsy is accurate and gives few false negative results.
Excisional biopsy also gives information that helps plan treatment, including:
Learn more about these factors.
In some cases, excisional biopsy is the only surgery needed to remove the tumor.
An excisional biopsy is a surgical procedure, so it is more invasive than a needle biopsy. The recovery time is longer and more uncomfortable. There is also a greater risk of infection and bruising. The amount of tissue removed can also change the look and feel of the breast.
If the biopsy results are benign (not cancer), then more surgery may have been done than was needed.
With incisional biopsy, only part of the tumor is removed. This procedure is only done when a tumor is too large to be removed with an excisional biopsy. Today, few people have an incisional biopsy.
An incisional biopsy is similar to an excisional biopsy, but less tissue is removed. The surgeon uses a local anesthetic to numb the area and you will also get IV sedation (rather than general anesthesia). You probably won't need to stay overnight in the hospital.
Since incisional biopsy only removes part of the tumor, more surgery will be needed to remove the remaining cancer.
The tissue removed is tested for signs of
cancer. If cancer is found, other tests can be done to help you and your
health care provider plan treatment.
In some cases, a biopsy can miss breast cancer.
With needle biopsies, this can happen if the needle takes a tissue or cell sample from the wrong area or if there is a problem with the sample. Even when samples are taken from the correct area, false negative results can occur if the pathologist misdiagnoses tissue or cells as benign when in fact, they are cancer.
With surgical biopsies, it is less likely that breast cancer will be missed, but this can still happen if the wrong area of tissue is removed. The use of needle- and wire-localization procedures before the biopsy and X-rays of tissue samples after the biopsy help limit this problem.
Learn more about getting a second opinion.
It is a myth that exposing breast cancer to air during surgery or cutting through the cancer might cause it to spread. Surgical and needle biopsies do not cause breast cancer to spread.
Facts for Life: Biopsy
Breast Cancer 101 - Discovery and Biopsy
Core Needle Biopsy Video
Ultrasound Guided Breast Biopsy Video
Surgical Biopsy Video
Questions to Ask Your Doctor About Biopsy
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