Stereotactic Breast Biopsy

Stereotactic breast biopsy uses mammography a specific type of breast imaging that uses low-dose x-rays to help locate a breast abnormality and remove a tissue sample for examination under a microscope. It's less invasive than surgical biopsy, leaves little to no scarring and can be an excellent way to evaluate calcium deposits or tiny masses that are not visible on ultrasound.

Tell your doctor if there's a possibility you are pregnant. Discuss any medications you're taking, including aspirin and herbal supplements, and whether you have any allergies. You will be advised to stop taking aspirin, blood thinners, or particular herbal supplements which can increase your risk of bleeding for three to five days before your procedure.

Don't wear deodorant, talcum powder or lotion under your arms or on your breasts for your procedure as these may appear on the mammogram.

Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown.

WHAT IS STEREOTACTIC (MAMMOGRAPHICALLY GUIDED) BREAST BIOPSY?

Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous.

A breast biopsy is performed to remove some cells from a suspicious area in the breast and examine them under a microscope to determine a diagnosis. This can be performed surgically or, more commonly, by a radiologist using a less invasive procedure that involves a hollow needle and image-guidance.

Image-guided needle biopsy is not designed to remove the entire lesion but to obtain a small sample of the abnormality for further analysis.

Image-guided biopsy is performed by taking samples of an abnormality under some form of guidance such as ultrasound, MRI or mammography.

In stereotactic breast biopsy, a special mammography machine uses x-rays to help guide the

radiologist's biopsy equipment to the site of the imaging abnormality.

WHAT ARE SOME COMMON USES OF THE PROCEDURE?

A stereotactic breast biopsy may be performed when a mammogram shows a breast abnormality such as:

• A suspicious mass
• Microcalcifications, which are a tiny cluster of small calcium deposits
• A distortion in the structure of the breast tissue
• An area of abnormal tissue changes
• A new mass or area of calcium deposits in a previous surgery site

Stereotactic breast biopsy is performed as a non-surgical method of assessing a breast abnormality. If the results show cancer cells, the surgeon can use this information for planning treatment.

HOW SHOULD I PREPARE?

You will be asked to remove some of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, removable dental appliances, eye-glasses and any metal objects or clothing that might interfere with the x-ray images.

Women should always inform their physician if there is any possibility that they are pregnant. Some procedures using image-guidance are typically not performed during pregnancy because radiation can be harmful to the fetus.

You should not wear deodorant, powder, lotion or perfume under your arms or on your breasts on the day of the exam.

Prior to a needle biopsy, you should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies. Your physician may advise you to stop taking aspirin, blood thinners, or certain herbal supplements for three to five days before your procedure to decrease your risk of bleeding. Also, inform your doctor about recent illnesses or other medical conditions.

WHAT DOES THE EQUIPMENT LOOK LIKE?

The specialized mammography machine used in this procedure is similar to the mammography unit used to produce mammograms.

A mammography unit is a rectangular box that houses the tube in which x-rays are produced. The unit is used exclusively for x-ray exams of the breast, with special accessories that allow only the breast to be exposed to the x-rays. Attached to the unit is a device that holds and

compresses the breast and positions it so images can be obtained at different angles.

A specially designed examination table will allow you to lie face down with your breast hanging freely through an opening in the table. The table is then raised and the biopsy procedure is performed beneath the table. The procedure may be performed while you sit in a chair.

Tissue sample is obtained using:

• A vacuum-assisted device (VAD), a vacuum powered instrument that uses pressure to pull tissue into the needle. This instrument rotates positions and collects multiple tissue samples through one needle insertion.

Other sterile equipment involved in this procedure includes syringes, sponges, forceps, scalpels and a specimen cup or microscope slide.

HOW DOES THE PROCEDURE WORK?

Mammography is a low-dose x-ray system designed to evaluate breast tissue.

A special digital mammography machine is used to perform a stereotactic breast biopsy. In digital mammography, as in digital photography, film is replaced by electronic detectors. These convert x-rays into electrical signals, which are used to produce images of the breast that can be immediately seen on a computer screen.

Stereotactic mammography pinpoints the exact location of a breast abnormality by using computer analysis of x-rays taken from two different angles. Using the calculated computer coordinates, the radiologist inserts the needle through a small cut in the skin, then advances it into the lesion and removes tissue samples.

HOW IS THE PROCEDURE PERFORMED?

Image-guided, minimally invasive procedures such as stereotactic breast biopsy is most often performed by a specially trained radiologist.

Breast biopsies are usually done on an outpatient basis.

In most cases, you will lie face down on a moveable exam table and the affected breast will be positioned into an opening in the table.

The table is raised and the procedure is then performed beneath it. If the machine is an upright system, you may be seated in front of the stereotactic mammography unit.

The breast is compressed and held in position throughout the procedure.

Preliminary stereotactic mammogram images are taken and reviewed by the radiologist. Once the radiologist identifies the abnormality on imaging, the computer will generate coordinate information and send it to the biopsy device.

A local anesthetic will be injected into the skin and more deeply into the breast to numb it. A very small nick is made in the skin at the site where the biopsy needle is to be inserted.

The radiologist then inserts the needle and advances it to the location of the abnormality using the mammogram and computer-generated coordinates. Mammogram images are again obtained to confirm that the needle is within the lesion prior to sampling.

Tissue samples are then removed, generally using a vacuum-assisted device. Typically, three to twelve samples are obtained, depending on the device used.

If calcium deposits (calcifications) are being sampled, an x-ray of the removed tissue will be obtained to document enough deposits were obtained for analysis under a microscope.

Additional sampling may be needed if not enough calcifications are identified initially. After the sampling is complete, the needle will be removed from the breast.

A final set of images will be taken.

A small marker may be placed at the biopsy site so that it can be located in the future if necessary.

Once the biopsy is complete, pressure will be applied to stop any bleeding and the opening in the skin is covered with a dressing. No sutures are needed.

A mammogram may be performed to confirm that the marker is in the proper position. This procedure is usually completed within an hour.

WHAT WILL I EXPERIENCE DURING AND AFTER THE PROCEDURE?

You will be awake during your biopsy and should have little discomfort. Many women report little pain and no scarring on the breast. However, certain patients, including those with dense breast tissue, or abnormalities near the chest wall or behind the nipple may be more sensitive during the procedure.

Some women find that the major discomfort of the procedure is from lying on their stomach for the length of the procedure, which can be reduced by strategically placed cushions.

Some women may also experience neck and/or back pain as the head is turned to the side when the breast is positioned for the biopsy.

When you receive the local anesthetic to numb the skin, you will feel a pin prick from the needle followed by a mild stinging sensation from the local anesthetic. You will likely feel some pressure when the biopsy needle is inserted and during tissue sampling, which is normal.

The area will become numb within a few seconds.

You must remain very still while the imaging and the biopsy are being performed.

As tissue samples are taken, you may hear clicks or buzzing sounds from the sampling instrument. These are normal.

If you experience swelling and bruising following your biopsy, you may be instructed to take an over-the-counter pain reliever and to use a cold pack. Temporary bruising is normal.

You should contact your physician if you experience excessive swelling, bleeding, drainage, redness or heat in the breast.

If a marker is left inside the breast to mark the location of the biopsied lesion, it will cause no pain, disfigurement or harm. Biopsy markers are MRI compatible and will not cause metal detectors to alarm.

You should avoid strenuous activity for at least 24 hours after the biopsy. Your biopsy facility will outline more detailed post-procedure care instructions for you.

WHO INTERPRETS THE RESULTS AND HOW DO I GET THEM?

A pathologist examines the removed specimen and makes a final diagnosis. Your referring physician will share the results with you. The radiologist will also evaluate the results of the biopsy to make sure that the pathology and image findings explain one another. In some

instances, even if cancer is not diagnosed, surgical removal of the entire biopsy site and imaging abnormality may be recommended if the pathology does not match the imaging findings.

Follow-up exams may be needed. If so, your doctor will explain why. Sometimes a follow-up exam is done because a potential abnormality needs further evaluation with additional views or a special imaging technique. A follow-up exam may also be done to see if there has been any change in an abnormality over time. Follow-up exams are sometimes the best way to see if treatment is working or if an abnormality is stable or has changed.

WHAT THE BENEFITS VS. RISKS?

BENEFITS

The procedure is less invasive than surgical biopsy, leaves little or no scarring and can be performed in less than an hour.

Stereotactic breast biopsy is an excellent way to evaluate calcium deposits or masses that are not visible on ultrasound.

Stereotactic core needle biopsy is a simple procedure that may be performed in an outpatient imaging center.

Compared with open surgical biopsy, the procedure is about one-third the cost. Very little recovery time is required.

Generally, the procedure is not very painful.

No breast defect remains and, unlike surgery, stereotactic needle biopsy does not distort the breast tissue or make it difficult to read future mammograms.

Recovery time is brief and patients can soon resume their usual activities. No radiation remains in a patient's body after an x-ray examination.

X-rays usually have no side effects in the typical diagnostic range for this exam.

RISKS

There is a risk of bleeding and forming a hematoma, or a collection of blood at the biopsy site. The risk, however, appears to be less than one percent of patients.

An occasional patient has significant discomfort, which can be readily controlled by non- prescription pain medication.

Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.

Depending on the type of biopsy being performed or the design of the biopsy machine, a biopsy of tissue located deep within the breast carries a slight risk that the needle will pass through the chest wall, allowing air around the lung that could cause the lung to collapse. This is an extremely rare occurrence.

There is a small chance that this procedure will not provide the final answer to explain the imaging abnormality.

There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant.

There are some instances in which stereotactic biopsy may not be possible, including if:

• The target abnormality is located near the chest wall or directly behind the nipple
• The mammogram shows only a vague change in tissue density but no definite mass or nodule
• The finding may be too subtle to identify at time of biopsy
• The breast is too thin
• The target is composed of diffuse calcium deposits scattered throughout the breast, which on occasion are difficult to target

Breast biopsy procedures will occasionally miss a lesion or underestimate the extent of disease present. If the diagnosis remains uncertain after a technically successful procedure, surgical biopsy will usually be necessary.