The menu of biopsies

Prof Carol-Ann Benn looks at biopsies in terms of a meal: starter, main and dessert, and explains what you should order and why.


Starter

A form of breast biopsy that examines individual cells (cytology) to determine whether the lump (tumour) is a cancer or not is known as a fine needle aspiration cytology (FNA or FNAC). 

The recipe for this pathology dish involves taking a small needle attached to a syringe and inserting it directly into the breast mass. If the mass is solid, several passes are made with some suction maintained on the syringe plunger. The suction is released before the needle is withdrawn, to avoid picking up red blood cells on the exit path of the needle which can contaminate the specimen. Several passes are made so that a representative of the total field sampled can be placed on a microscope slide where it’s air-dried or fixed. Furthermore, completion of the dish (herbs and spices) requires a chemical stain for additional information and for cell receptor analysis to be done. This helps determine whether the cells are benign (non-cancerous) or malignant (cancerous). FNA is usually the dish of choice for cystic lesions. Cysts can be aspirated till dryness with this technique.

If there is a mass post aspiration, this residual mass should be biopsied with a core needle (main meal). If the fluid is bloodstained (red, black or brown), as a general rule the aspirate should always be sent for testing. 

Unguided biopsies, particularly FNA, lead to inconclusive cytology results (this is like blindly putting a mix of ingredients together with no idea of what the dish is). FNA alone is a poor test to determine any characteristic of the lesion. Malignant cells are seen but one can’t conclude whether the cancer is invasive or in-situ, nor can hormone-receptor status, grade or type be determined accurately.

Main meal

A core needle biopsy is the main meal and the current gold standard for diagnosis in breast disease. The lump or area seen on the mammogram or ultrasound is biopsied for analysis by taking a core of tissue which is then sent for histopathology (this is the high-tech photo taken by a professional). 

Don’t be scared of this procedure as local anaesthetic is given, and although the devise used (either a hand-driven device or pneumatic gun) looks scary and intimidating, the extra tissue allows the pathologist to determine the type of cancer. This includes characteristics, such as grade, proliferation (activity) and invasion as well as testing for certain receptors, such as oestrogen, progesterone and HER2/neu receptor presence (clothes the cancer is wearing).

A fancy core is a vacuum-assisted core biopsy that takes multiple contiguous cores. The vacuum pulls tissue into the probe aperture whilst a high-speed, rotating cutter slices the tissue and a vacuum transports tissue to a collection chamber while the probe remains in the breast. This clever devise allows for multiple samples. 

Check the price of the main meal

Remember when you order a meal, you check the price on the menu. The same goes for these biopsies; you must have an understanding of the cost, and they should never be done without your consent as they aren’t emergency procedures. The hidden costs are the laboratory costs. Particularly if the tests come back as benign, then these costs may need to come out of your savings.

When areas, such as small calcifications or non-palpable breast masses, are found on screening mammography, a form of stereotactic (mammogram guided) core-biopsy is used by the radiologist, as the lump is not yet palpable. These silent breast masses can be accurately localised using the computer technology built-in the mammogram apparatus. The silent lesion undergoes a core biopsy first to determine what it is as opposed to just cutting them out with various wire or localisation techniques. 

Core biopsies are accurate and don’t spread cancer cells. They allow the doctor to plan surgery definitively, or alternatively other oncology options prior to surgery. By performing this procedure in an awake patient under local and then discussing the results in a multi-disciplinary meeting, the concept of controlled-informed consent allows the patient to have a say in all the processes.  

Don’t start the meal with dessert

The only time a surgical biopsy (dessert) is done to determine what something is, is when an area on mammogram is suspicious and a needle biopsy result is inconclusive, unsuccessful or equivocal. 

If the excision is for diagnosis, no further tissue should be taken except the suspicious area. Taking a margin of normal tissue will result in an unnecessarily large hole if the lesion is benign. If malignant, the patient will usually require further surgery at least to manage the axilla and possible to excise any remaining margins.

This is why we want the menu with all information before we start treating a cancer with surgery.

Understand the SQ of the menu and avoid buffets

Don’t rush into radiological-guided biopsies. No biopsy needs to be done at the time of mammogram or ultrasound, and all indications for biopsy should be discussed fully with the person first. The patient should understand the indications and cost before consenting. Informed consent implies you taking time and understanding all the pros and cons.

When biopsies are inconclusive, bloody or indeterminate, the solution is often thought that bigger is better and off we order a surgical excision. 

Again, full review prior to rushing into further procedures is the answer. You may know CPR means cardio-pulmonary resuscitation; that life-saving technique. Well breast CPR stands for clinical, pathology, and radiology review prior to rushing into any surgery. Concerning issues associated with a surgical biopsy are three-fold: financial (F); oncologic (O); and cosmetic (C). FOC (a very bad word). The more tissue that is removed from the breast, the more likely it will be distorted and disfigured. The cost is high: in time off work, hospital admission and cost of procedure. In addition, it’s a fallacy that a surgical biopsy provides both diagnosis and treatment. 

Actually, a surgical biopsy means more operations are usually required for margin clearing or axillary surgery (checking the drainage glands), and in many cases, it limits the type of breast-conserving surgery that can be offered later. The goal of biopsy, whether by needle or surgery, is to diagnose and not treat.

International rules of the menu

All international guidelines agree that less than 10% of all cancer diagnoses should be based on a surgical biopsy and these should be reserved for very rare indications: areas very near to implants or the chest wall (today this is almost never as most specialised radiologists can biopsy these areas); patient choice (this again should be never as who wants to be asleep and not in control of what is happening); or a lesion not seen on any imaging (MRI has largely ensured that this too doesn’t happen), and anyway how can you not see the lesion on radiology but think that you can cut it out without knowing where it is. 

So, understand what’s on the menu and when you have to order. Go for the radiology-guided core biopsy that leaves you with a pin-prick scar and minimal pain, avoid a costly hospital admission, see a breast specialist or doctor who is able to give definitive reassurance of a benign lesion, or discuss a multi-disciplinary management plan if a breast cancer diagnosis is made.

Prof Carol-Ann Benn heads up internationally accredited, multi-disciplinary breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established The Breast Health Foundation.

MEET THE EXPERT – Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up internationally accredited, multi-disciplinary breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established The Breast Health Foundation.


Header image by Adocbe Stock