New Breast Biopsy Techniques Allow ‘One-Stop’ Procedures

TOWSON, Md—New breast biopsy techniques are making it more likely that one-stop procedures will become standard of care for small lesions. With this technique, lesions are sampled and removed for biopsy in a minimally invasive procedure, said Rachel Brem, MD, assistant professor of radiology and oncology at the Johns Hopkins Medical Institutions’ Breast Imaging Center.

“It is likely that in the future we will transition from diagnostic to therapeutic uses of minimally invasive techniques,” Dr. Brem said at Seeking Excellence in Breast Cancer Care, a conference sponsored by Hopkins. Dr. Brem outlined the advantages and disadvantages of currently used sampling techniques that are less invasive than standard surgical methods.

Fine-needle aspiration is extremely operator dependent, she said. Tissue architecture is not retained in the sample, and 15% to 77% of such biopsies result in insufficient sample.

The stereotactic large-core needle approach, in addition to its minimal invasiveness, uses computer coordinates for precision in locating lesions. It provides a surgical-quality sample in which tissue architecture is maintained, takes only 1 hour, requires no intravenous anesthesia, and costs $700 to $800, compared with $3,000 to $4,000 for surgical biopsy, she said.

The stereotactic large-core approach, unlike surgery, also results in no post-procedure mammographic distortion and is well accepted by patients, Dr. Brem said. Some of the disadvantages are that the procedure is difficult to perform on “pancake” breasts and may not give good results in breast wall lesions or lesions with a negative stroke margin, she said.

Vacuum-assisted biopsy is useful for smaller lesions, particularly microcalcifications. Where a large-core needle may be akin to chasing a tiny object in gelatin and may require many needle insertions, the vacuum-assisted device can pull the tissue in and sample more in nearby areas with only one needle insertion, Dr. Brem said.

In cases where the whole lesion is removed, a tiny metal clip may be inserted at the lesion’s location in the breast. If the lesion turns out to be cancerous or suspicious, surgery will still be needed to check margins and acquire any further pathologic information needed. The surgeon will then be able to find the area easily by locating the clip, Dr. Brem said. If the lesion is benign, the clip is left in place.

Whether therapeutic removal of a cancerous lesion at initial biopsy is a viable option is “certainly an issue people have thought about, but we haven’t been doing it (one-stop removal) long enough to know,” she said. There is concern because the biopsy can cut across a lesion’s margins, but that occurs in 30% of surgeries as well.

“We have every reason to believe it will prove safe and effective for small lesions,” she said of one-stop removal. “My hope is that both the psychological and physical impact of having breast cancer are going to be reduced.”