Breast
General
Core biopsy
Author: Hind Warzecha, M.D.
Last author update: 1 April 2010
Last staff update: 3 September 2021
Copyright: 2002-2024, PathologyOutlines.com, Inc.
PubMed Search: Core biopsy [title] of breast lesions [title]
Table of Contents
Definition / general | Core biopsy versus fine needle aspiration biopsy | Guidance modalities | Technical details | False negatives | Complications | Reporting system of UK National Health Service Screening Programme | Diagrams / tables | Microscopic (histologic) imagesCite this page: Warzecha H. Core biopsy. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastcore.html. Accessed April 20th, 2024.
Definition / general
- See also discussion of core biopsies under specific diagnoses and core biopsy imprint cytology as part of cytology topic
- Percutaneous large core needle biopsy using stereotactic mammography or ultrasound guidance is routinely used to evaluate clinically occult breast lesions and is an alternative to open biopsy for many patients
- Recommended as the initial diagnostic procedure in patients with suspicious mammograms, due to association with improved pathologic margins and fewer surgical procedures (Breast J 2008;14:471)
- May be an alternative to surgery for some lesions (Breast 2008;17:546, Radiology 2008;248:406)
- Has led to reduction in surgical interventions after benign or negative diagnoses (Eur J Cancer 2008;44:2580)
- Overall high level of interpathologist agreement (Am J Surg Pathol 2004;28:126)
- Diagnostic performance is comparable to excisional specimens (Int J Cancer 2008;122:468) but tumor grade in invasive carcinoma may differ (Am J Surg Pathol 2003;27:11, Am J Surg 2009;197:266)
- Performing imprint cytology on core may be useful for rapid diagnosis (Cytopathology 2008;19:311)
- eMedicine: Breast Stereotactic Core Biopsy / Fine Needle Aspiration, National Breast Cancer Centre: Breast Fine Needle Aspiration Cytology and Core Biopsy: A Guide for Practice, First Edition, 2004
Core biopsy versus fine needle aspiration biopsy
Core biopsy is favored over fine needle aspiration because core biopsy:
- Is useful for evaluating cytologic and architectural characteristics and diagnosing invasive carcinoma (Diagn Cytopathol 2007;35:681)
- Is more reliable (Acta Radiol 2008;49:863)
- Reduces need for additional biopsies (Acta Oncol 2008;47:1037)
Guidance modalities
MRI directed breast excision:
Definition / general:
Indications:
Clinical features:
- Widely used in U.S. (AJR Am J Roentgenol 2008;191:332)
- MRI cannot verify that suspicious lesion is in specimen (unlike traditional radiography) because MRI requires IV injection of gadolinium and uptake into suspicious area, which cannot be done after specimen has been excised
- References: eMedicine: Breast Biopsy With Needle Localization
Indications:
- Screening of high risk women for breast cancer (AJR Am J Roentgenol 2003;181:619, Cancer 2005;103:1898)
- Monitoring response to neoadjuvant chemotherapy (Radiology 2007;244:672)
- If uncertain diagnosis on mammography, ultrasound or clinically (AJR Am J Roentgenol 1999;173:1323)
- If lymph node metastases from unknown primary (Radiology 1999;212:543)
Clinical features:
- Low (87%) sensitivity for diagnosing mammographically detected microcalcifications (AJR Am J Roentgenol 2006;186:1723)
- Recommended to submit entire specimen for microscopic examination because usually no gross findings (Hum Pathol 2007;38:1754)
- Complete removal of MRI target does not ensure complete histologic excision of the cancer (AJR Am J Roentgenol 2008;191:1198)
- MRI guided vacuum assisted biopsy may provide an alternative to surgery and MRI guided needle biopsy (AJR Am J Roentgenol 2003;181:1283)
- May overestimate gross tumor size (AJR Am J Roentgenol 2003;181:1283)
Technical details
- First generation: computer assisted stereotactic mammography or ultrasound used to localize target lesion, then automated spring loaded biopsy gun was used, usually with 14 gauge cutting needle
- Second generation: includes Mammotome (Breast Cancer 2007;14:292, World J Surg Oncol 2007;5:83); uses vacuum assistance to draw tissue into the needle and permits use of larger caliber needles (8 to 11 gauge) and more thorough sampling of lesions (thicker, longer, multiple specimens with single needle insertion)
- Processing: should routinely obtain 3 - 5 deeper levels; 5 levels recommended to detect ADH and atypical proliferations (Arch Pathol Lab Med 2001;125:1055) or minimally invasive carcinoma (Arch Pathol Lab Med 2004;128:996); but see Mod Pathol 2001;14:350
- May need only one level routinely for MRI detected lesions (Arch Pathol Lab Med 2009;133:1961)
- Underestimation of findings compared to excision is comparable with 9 or 12 gauge needles (Breast Cancer 2011;18:42)
- Some recommend routine radiologic examination of cores for microcalcifications and deeper levels if microcalcifications are not in slide
- Minimal invasion in core biopsies (1 mm or less) is usually associated with invasive tumors of 1 cm or more at excision (Arch Pathol Lab Med 2004;128:996)
- Rarely mastectomy (or excisional biopsy) after malignant core biopsy will show no cancer (Mod Pathol 1997;10:1209)
- Immunostains for ER, PR and HER2 show 85 - 95% concordance with excision specimens (Acta Oncol 2008;47:38, Pathology 2007;39:391); substantial discordance for PR in some studies (Ann Oncol 2009;20:1948)
- Not associated with significant bleeding in patients on anticoagulant therapy (AJR Am J Roentgenol 2008;191:1194)
- Cytopathologists may be able to perform ultrasound guided FNAs and core biopsies (Diagn Cytopathol 2008;36:317)
False negatives
- Radiologic - histologic correlation: must determine if histologic results provide a sufficient explanation for the imaging features - if not, lesion may not have been adequately sampled
- Most false negatives are due to radiologic - histologic discordance and are discovered immediately (Eur Radiol 2010;20:782, Eur J Cancer 2010;46:1835)
- Follow up imaging is recommended, even in patients with concordant benign findings (Radiographics 2007;27:79)
Complications
- Seeding / displacement of normal epithelium along needle tract, particularly with papillary lesions, which may simulate malignancy (Arch Pathol Lab Med 2005;129:1465)
- Seeding of tumor cells along needle tract (Breast Cancer Res Treat 2008;110:51), particularly intracystic papillary carcinoma (J Clin Pathol 2002;55:780)
- Seeding of tumor cells into lymphovascular spaces (Am J Clin Pathol 2010;133:781)
- Reactive spindle cell proliferation
- Epidermal inclusion cyst
- Pseudoaneurysms are rare (Breast Cancer 2010;17:75)
Reporting system of UK National Health Service Screening Programme
- B1: normal tissue / inadequate sample (comment on microcalcifications and specimen adequacy)
- B2: benign lesion (specify)
- B3: uncertain malignant potential (includes radial scar, some papillary lesions, ADH, lobular neoplasia)
- B4: suspicious of malignancy (suggestive but not diagnostic due to scanty material or artifacts)
- B5: malignant; specify if invasive or not, if possible; indicate grade of DCIS
- References: J Clin Pathol 2004;57:897
Diagrams / tables
Images hosted on other servers:
Mammotome
Microscopic (histologic) images
Images hosted on other servers:
Displaced epithelial cells; #2 - intracystic papillary carcinoma
Detached clusters
of ductal carcinoma
in situ from
pre-existing ducts
