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Breast Stereotactic Core Biopsy/Fine Needle Aspiration

Overview

The establishment of national breast-screening programs in Europe and North America led to an increase in the detection of small or impalpable breast lesions. The ability to achieve an accurate histopathologic diagnosis of these lesions is crucial to any screening program in terms of appropriate treatment planning and patient counseling.

Stereotactic breast needle biopsy refers to the sampling of nonpalpable or indistinct breast lesions by using techniques that enable the spatial localization of the lesion within the breast. The word stereotactic is derived from Greek and Latin roots meaning “touching in space.” Stereotactic techniques have evolved in parallel with the trend in breast conservation and minimally invasive surgery.

In the past, impalpable breast lesions would have been surgically excised after needle localization, resulting in a vast number of surgeries for nonmalignant mammographic abnormalities. In the United States, it is estimated that more than a million surgical breast biopsies are performed, and in only 15%-30% are the samples subsequently found to be malignant.

Role of stereotactic needle biopsy

Compared with open surgical biopsy, needle biopsy causes less trauma and disfigurement and is performed as an outpatient procedure with the patient under local anesthetic.
 Stereotactic needle biopsy is an important tool in the diagnosis of breast lesions as part of the triple assessment, which includes clinical, radiologic, and cytohistopathologic studies.

Definitively diagnosing these lesions with needle biopsy has several advantages. For benign lesions, establishing a definitive diagnosis obviates unnecessary surgical excision or protracted follow-up, both of which are costly in psychosocial and resource terms.
 A definitive diagnosis of cancer allows the patient to make an informed choice and to obtain counseling before surgery. It also facilitates in the planning of multimodal treatment in terms of neoadjuvant chemotherapy, the type of procedure, and early or delayed reconstruction.

The importance of achieving preoperative diagnosis is further emphasized in the quality objectives of the United Kingdom’s national breast-screening program to minimize unnecessary benign surgical biopsy and to ensure that more than 70% of women with cancer have a preoperative diagnosis.

Techniques and principles of stereotaxis

Because most of the lesions detected during screening are impalpable, subsequent needle biopsy must be image-guided. Ultrasonography-guided biopsy is usually the most straightforward approach, but lesions better seen on mammography images, particularly microcalcifications, require stereotactic localization.

The principles of localization involve mapping the distance between the geometric center of the breast with the target lesion in two different planes and then projecting the coordinates onto the patient’s breast (see image below).

Stereotactic images obtained during a prone-table

Stereotactic images obtained during a prone-table biopsy procedure.

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Earlier techniques in stereotaxis used mammographic projections to localize the target lesion within the breast. Advances in digital mammography have since superseded manual computations. Dedicated stereotactic equipment that performs localization with fixation of the breast is now in use (see image above).
 Stereotactic techniques have also been developed within other imaging modalities, including ultrasonography and magnetic resonance imaging (MRI). These techniques offer more options and greater flexibility in performing stereotactic biopsy.

Digital tomosynthesis creates a three-dimensional (3-D) picture of the breast using x-rays. It has been approved by the US Food and Drug Administration (FDA), but it is not yet considered the standard of care for breast care screening and is only available in limited hospitals. It takes multiple x-ray pictures of each breast from many angles. The breast is positioned in the same way as conventional mammography but with limited pressure. The x-ray tube moves in an arc around the breast while numerous images are taken within a few seconds. The information is then relayed to a computer, which generates highly focussed 3-D images throughout the breast.

In 2013, Hologic Inc launched the world’s first 3-D breast biopsy option “Affirm 3D”. The procedure can be of benefit in targeting lesions that cannot be easily detected on two-dimensional (2-D) imaging or when using other modalities. It is claimed to also target lesions faster and reduce patient procedure time.

Relevant Anatomy

The breast is made up of fatty tissue and glandular, milk-producing tissues. The ratio of fatty tissue to glandular tissue varies among individuals. In addition, with the onset of menopause (ie, decrease in estrogen levels), the relative amount of fatty tissue increases as the glandular tissue diminishes.

The base of the breast overlies the pectoralis major muscle between the second and sixth ribs in the nonptotic state. The gland is anchored to the pectoralis major fascia by the suspensory ligaments first described by Astley Cooper in 1840. These ligaments run throughout the breast tissue parenchyma from the deep fascia beneath the breast and attach to the dermis of the skin. Since they are not taut, they allow for the natural motion of the breast.

For more information about the relevant anatomy, see Breast Anatomy.

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