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Stereotactic Breast Biopsy: Indications and Results

Stereotactic Breast Biopsy: Indications and Results

ABSTRACT: Imaging-guided breast biopsy performed with large-core needles can accurately diagnose most breast pathologies, often allowing a diagnosis to be made more quickly and less expensively than with surgical biopsy. Major complications, such as hemorrhage and infection, are extremely rare, although post-biopsy ecchymosis and tenderness are not unusual. Because less tissue is removed, post-biopsy cosmetic deformity does not occur. Stereotactic biopsy is performed by triangulating the position of a breast lesion and by obtaining views angled equally off a central axis. This can be done using dedicated tables or add-on equipment. Stereotactic core biopsy has a reported accuracy of at least 90%. All lesions for which biopsy would ordinarily be recommended are amenable to stereotactic techniques, but those near the chest wall or in the axilla may be more difficult to biopsy with some equipment. Lesions characterized by calcifications are sometimes more difficult to sample. A biopsy diagnosis of ductal atypia, because of its histologic heterogeneity, requires surgical excision to exclude coexistent carcinoma, which has been found in half of women at subsequent surgical excision. A core biopsy diagnosis of ductal carcinoma in situ does not preclude the discovery of invasive carcinoma at surgery. In rare instances, the small tissue volume removed at stereotactic biopsy does not permit a final diagnosis to be made; this occurs most commonly when differentiating phyllodes tumor from fibroadenoma.[ONCOLOGY 12(6):907-922, 1998]

Main article not available.


The Dershaw/Liberman Article Reviewed

RICHARD C. FRAZEE, MD
Scott & White Clinic and Memorial Hospital
Texas A&M University Health Science Center
College of Medicine
Temple, Texas

Methods for detecting breast cancer are evolving as new technology
provides a wider range of options for screening and definitive
diagnosis. In addition to mammography and physical examination,
screening techniques now include ultrasonography, technetium-99m
sestamibi nuclear scanning, and magnetic resonance imaging. Despite
the availability of these newer modalities, physical examination and
screening mammography remain the standards for detecting suspicious
breast abnormalities.

Core-needle biopsy has been used for many years by surgeons to
evaluate palpable breast abnormalities and is now a well-accepted
technique for the definitive diagnosis of breast carcinoma. With this
procedure, sufficient tissue can be obtained to perform histologic
studies and determine hormone-receptor status. The diagnostic
accuracy of core-needle biopsy exceeds that of fine-needle aspiration
cytology, which carries a false-negative rate of approximately 15%
and a false-positive rate of approximately 0.5%.

"Advantages" of Stereotactic Biopsy Over Open Biopsy

Refinements in breast ultrasound and stereotactic imaging have now
led to image-guided core-needle biopsy. Drs. Dershaw and Liberman are
to be complimented for presenting a thorough review of the literature
on the indications and results of stereotactic core-needle biopsy. As
with many articles on this subject, the authors point out the
"advantages" of stereotactic biopsy over open surgical biopsy.

According to the authors, one "advantage" is the ability to
streamline the evaluation process by eliminating the need for
evaluation of the patient by the surgeon prior to stereotactic
biopsy. Eliminating prebiopsy physical examination by an experienced
breast surgeon is not necessarily desirable, for several reasons:

1) A significant number of mass lesions initially detected on
screening mammogram are palpable on direct physical examination, and
these lesions can be further evaluated by palpation-guided biopsy at
a lower cost than stereotactic biopsy.

2) Hematoma formation following stereotactic biopsy, which occurs in
2% to 5% of patients, impairs the surgeon’s ability to judge the
size of lumpectomy required in breast-conserving therapy.

3) Prebiopsy discussion with the surgeon allows the patient to
receive more complete information regarding the choice of biopsy procedure.

Thus, the potential benefits of a thorough prebiopsy evaluation by
the surgeon outweigh any advantage in time savings afforded by
stereotactic biopsy.

The authors also state that there can be long delays in obtaining
pathologic reports following surgical biopsy, leading to increased
patient anxiety. Such delays are likely a function of institutional
obstacles, as no medical reason exists to preclude timely diagnosis
following surgical biopsy.

Retrospective reports have noted higher satisfaction and less pain
with stereotactic biopsy than with open biopsy.[1,2] This finding was
not borne out in a prospective evaluation performed at Texas A&M
University Health Science Center.[3] We saw no differences between 51
women who underwent an open biopsy and 52 who had stereotactic biopsy
with regard to patient satisfaction, procedural pain, or return to
activities following biopsy.

Accuracy of Stereotactic Biopsy vs Open Biopsy

The accuracy of stereotactic biopsy approaches that of open biopsy,
with a few recognized pathologic exceptions. Dershaw and Liberman
correctly point out that biopsy results that are discordant with the
physical examination and mammographic findings raise the concern that
a lesion may have been missed. Reports of carcinoma in situ, atypical
ductal hyperplasia, and radial scar on stereotactic biopsy also
should be viewed with caution and should prompt performance of an open biopsy to rule out invasive carcinoma. All patients, regardless of the type of
biopsy that they received, should return in 6 months for a follow-up
examination and mammogram to provide a new baseline and ensure that
the abnormality has not progressed.

One of Several Acceptable Options

Although stereotactic biopsy has a few recognized limitations, it is
one of several acceptable options for diagnosing breast cancer. As is
the case for the expanded options for treating breast cancer,
patients can play an increased role in the selection of biopsy type.
It is important that patients are educated about the various biopsy
types so that they can make an informed decision as to which
technique will best serve their needs.


--Richard C. Frazee, MD

References

1. Parker SH, Burbank F, Jackman FJ, et al: Percutaneous large core
breast biopsy: A multi-institutional study. Radiology 193:359-364, 1994.

2. Liberman L, Fahs MC, Dershaw DD, et al: Impact of stereotaxic core
breast biopsy on cost of diagnosis. Radiology 195:633-637, 1995.

3. Frazee RC, Roberts JW, Symmonds RE, et al: Open vs stereotactic
breast biopsy. Am J Surg 172:491-493, 1996.

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