What is the role of breast stereotactic core-needle biopsy in the workup of breast lesions?

Updated: Aug 09, 2018
  • Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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In view of the limitations with FNA, core-needle biopsy was developed. The core needles are of a larger caliber than the fine needles and are mounted onto a spring-loaded device that allows small cylinders of tissue to be cut and collected within the notch of the needle. Technically, the best core-biopsy samples are obtained by using 14-gauge needles. The optimal number of passes required vary according to the mammographic appearances of the lesions being sampled, with fewer passes required for solid lesions compared with microcalcifications. Several investigators have shown that a minimum of five to six passes is required when sampling microcalcifications to minimize sampling error. [25, 26, 27]  Specimen radiography is also required to ensure that representative calcifications are obtained (see image below).

Comparison of the size of specimens obtained durin Comparison of the size of specimens obtained during core biopsy with a 14-gauge needle (left) and those obtained during vacuum biopsy with a 16-gauge needle (right).

A few false-positive results are reported, and these are attributed to the removal of the lesion by means of core biopsy or a surgical failure to remove the lesion. The reported false-negative rate for malignancy with core biopsy is in the range of 2% to 6.7%, with a mean rate of 4.4%. [28, 29]  These false-negative results are more likely to occur with microcalcifications. In the United Kingdom's National Health Service (NHS) Breast Screening Programme, the actual false-negative rate is more variable. [7, 30]  This variation may represent the wide range of experience and expertise in the technique, as some units may still be moving from FNA to core biopsy.

Although the vast majority of the published literature on stereotactic core biopsy involves the use of dedicated, prone-table biopsy units, better results have been reported in United Kingdom centers that switch from FNA to core biopsy by using upright stereotactic devices. [31, 32]  With the advent of digital acquisition with upright stereotactic units, the accuracy could reasonably be expected to improve, and this improvement has certainly been the experience with early adopters of such systems (Evans AJ, personal communications, 2003).

The main advantage of core-needle biopsy is that it enables histologic diagnosis, which is vital to the planning of subsequent surgery and treatment of the patient. Stereotactic core-needle biopsy using a 14-gauge needle is widely accepted to be sensitive (90.5%) and specific (98.3%) in diagnosing breast masses, compared with 62.4% and 86.9%, respectively, for FNA. Core-needle biopsy can also be used to detect in situ as well as invasive malignancy. In addition, the status of estrogen receptors in the samples can easily be ascertained.

Certain histologic results should be interpreted with caution. With core biopsy, a propensity to underestimate certain pathology exists. [33]  Over 50% of all cases of atypical ductal hyperplasia (ADH) diagnosed with core biopsy prove malignant at surgery, and invasive carcinoma is found in up to 33% of core biopsy-confirmed ductal carcinoma in situ (DCIS). [16, 19, 20]

Radial scars diagnosed by means of core biopsy should also be regarded as high-risk lesions requiring excision. [29]  It is also more difficult to achieve a diagnosis using core biopsy in low-risk calcifications or where the underlying cause is subsequently proven to be benign. [34]  Therefore, core biopsy results should always be carefully analyzed to ensure that radiologic and pathologic concordance exists. One case report also raised concerns of malignant seeding of the needle track after core biopsy of a mucinous carcinoma [35] ; however, the significance and true incidence of this phenomenon remains uncertain


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