A 54-year-old woman presents with a palpable abnormality in the right breast. She has no personal or family history of breast cancer. A palpable lump is present in the right breast at the 5 o’clock retroareolar position. There are no skin changes, nipple discharge or palpable axillary nodes.
Her routine screening mammogram a year ago was reported as normal. Her current diagnostic bilateral 3D breast tomosynthesis study showed extreme breast density. The right breast mammogram showed a noncalcified density with a partially circumscribed margin correlating with the palpable lump. The diagnostic ultrasound demonstrates a suspicious mass lesion in the right breast 5 o’clock position (Figure 1A) with right axillary lymphadenopathy (Figure 1C).
DISCUSSION
A specialist breast radiologist’s role is to address the referrer’s clinical questions and correlate the clinical symptoms with imaging and histopathology. The triple test assessment should be completed when dealing with all breast disease including screening and symptomatic issues.
The ‘triple test’ assessment is comprised of three fundamental diagnostic components:
- Medical history and clinical breast examination (CBE) including clinical findings, nature, and duration of the symptoms, the exact lesion location, personal and family history of breast cancer, presence of breast implants, information regarding anticoagulation and HRT medications, and any previous radiotherapy or chemotherapy.
- Imaging – mammogram and/or ultrasound
- Non-excisional biopsy – fine needle aspiration (FNA) cytology and/or core biopsy.
Managing patients with a suspicious mass on imaging can be expedited if a referral to perform an image-guided breast procedure at the time of the patient’s radiology appointment was available. Ultrasound-guided core biopsy is the preferred method for sampling (Figure 1B).
Unfortunately, this patient did not have a biopsy request and the referrer was not available on the day, thus biopsy procedure was organised the following week. This can be challenging in remote or rural areas. If the patient is taking anticoagulants, discuss this with the radiologist before organising a possible biopsy procedure. A biopsy is considered safe where INR is < 1.6. Patients taking other anticoagulants are generally advised to stop these two to three days before their appointment.
There are three types of image-guided breast procedures: fine needle aspiration, core biopsy and vacuum-assisted core biopsy.
Fine needle aspiration is a minimally invasive procedure to remove cells or fluid from a breast lesion using a 21-27 gauge needle. It is done to aspirate symptomatic breast cysts and atypical cysts, drain an abscess or seroma and sample an abnormal-looking axillary lymph node (Figure 1D). FNA is an alternative sampling method for patients taking anticoagulants in rare situations.
Breast core biopsy is done to collect small cores of tissue using a 14-18 gauge hollow needle from an abnormal area. The procedure provides more specificity as compared to FNA, it has the additional advantage of ancillary tests and comments on the histopathological prognostic and hormonal markers. This is indicated in patients with breast lesions that are not palpable, small, and calcified. A core biopsy is recommended for inconclusive or non-diagnostic FNA and to differentiate between carcinoma in situ (DCIS/LCIS) and invasive carcinoma (IDC/ILC).
Vacuum-assisted core biopsy (VACB) uses a vacuum-powered device to obtain tissue samples from the breast using a 7-12 gauge needle. It is performed percutaneously under local anaesthesia as an outpatient procedure under ultrasound, mammogram or MRI guidance.
This is indicated to sample indeterminate calcifications, small mass or architectural distortion only seen on MRI or mammogram and a previous core biopsy (14g) considered non-diagnostic. There is no post-procedure care with FNA.
For core biopsy and VACB, the skin incision will be secured with steri-strips and covered with a waterproof dressing. An icepack is placed over the biopsy site to avoid further bruising. Patients are advised to take paracetamol for pain relief (not aspirin).
Contraindications
There are no absolute contraindications to FNA and core biopsy unless sampling needs to be performed under MRI guidance.
FNA has a theoretical risk of damaging breast implants, but this is avoided with imaging guidance performed by experienced specialist breast radiologist.
Core biopsy and VACB are relatively contraindicated in patients taking anticoagulants such as warfarin to avoid bleeding, obesity due to prone tables weight limitation and lactation which has a very small risk of developing milk fistula.
All three procedures exhibit common adverse effects (less likely in FNA) such as bruising, haematoma formation (less than 1%), infection (less than 0.1%), and breast pain. Pain can be relieved by the intake of paracetamol. There is a rare possibility of secondary haemorrhage from arterial bleeding in core biopsy and VACB which is usually controlled by local pressure. However, if this is not successful, a surgical intervention may be needed.
Key messages
- The role of imaging is to answer a clinical question
- Dual referral for imaging and procedure can be expeditious
- The biopsy is generally safe with INR under 1.6.
– References available on request
Author competing interests – nil