What Are the Types of Biopsy for Breast Cancer?
If your doctor suspects breast cancer, you’ll likely have a biopsy to confirm the diagnosis.
By Elaine K. Howley
Breast cancer is the most common type of cancer in women and often, the first sign appears as either a lump in the breast that can be felt through the skin, or that shows up on an annual mammogram screening.
If you find a lump, or if your doctor notices something on one of your mammogram images that warrants further investigation, you’ll likely be scheduled for a biopsy.
During a breast biopsy, a sample of the tissue in question is removed from the body and sent to the pathology lab for further testing. It’s a commonly-used diagnostic tool that can help your doctor determine whether or not you have cancer.
But a breast biopsy isn’t the same experience for all patients. Depending on the location and characteristics of the lump or suspicious area, you may have one of a few different types of biopsies, which include:
- Needle biopsy.
- Vacuum-assisted breast biopsy.
- Surgical biopsy.
- Lymph node biopsy.
Any and all of these types of biopsies may be performed with image guidance from MRI, ultrasound or mammogram technology.
“Needle biopsies are the first line of diagnosis,” for breast cancer, says Dr. Michele Carpenter, the breast program director at the Center for Cancer Prevention and Treatment at Providence St. Joseph Hospital in Orange, California. Needle biopsies come in two main varieties:
- Fine needle aspiration.
- Core needle biopsy.
Fine needle aspiration is conducted on easily accessible lumps or suspected fluid-filled cystic lumps. As the fluid is withdrawn from the area, if it’s a cyst, it will collapse and the problem will resolve itself. The fluid that’s been removed is then sent to the lab to be tested for the presence of cancer cells. This is the least invasive type of biopsy and usually leaves no scar.
Carpenter notes that the fine needle aspiration looks “at individual cells instead of a ‘piece’ of the tissue. This is the difference between looking at a brick in a wall as opposed to the wall itself.”
Dr. Jeffrey Hawley, a radiologist with the Ohio State University Wexner Medical Center, says these types of biopsies are less commonly used. “Basically, you’re just suctioning out a few cells” from the suspected tumor or lesion and putting those cells on slides for the pathologist to look at under a microscope. “There are some disadvantages to that,” he says.
For example, “if it does turn out to be positive for cancer, the pathologist is not going to be able to run the biomarkers off that sample,” meaning that there’s not enough tissue present to determine whether the cancer uses estrogen or progesterone to feed its growth, a critical piece of information that will help guide your treatment options.
Because this is challenging to do with such a small sample size, the patient may have to go back and have another biopsy. Therefore, Hawley says “we typically do a core needle biopsy up front.”
Core needle biopsy is used to extract cells from the center of a lump or suspicious area in the breast. Hawley says these procedures use “larger needles, typically a 14- or 18-gauge needle.” The doctor puts the needle “into the mass and takes out small, little cores of the tissue.” The needle is typically inserted three to six times.
“These biopsies are performed with guidance by ultrasound or mammogram or MRI,” Carpenter says, because that “helps us to be able to do more studies on the larger piece of tissue.”
The tissue samples that are extracted “look like little pieces of spaghetti,” Hawley says. Those tissue samples are then sent off to the pathology lab for diagnosis. “We typically use core needle biopsy for most anything,” he says. Patients will likely receive a local anesthetic during a core needle biopsy, and there could be some small scarring afterwards.
Vacuum-assisted Breast Biopsy
Vacuum-assisted breast biopsy is similar to core needle biopsy, but instead removes more tissue through a single insertion of a special probe. It’s a relatively new procedure also called minimally invasive breast biopsy, and it's not as widely available as other types of biopsies. It’s typically conducted under a local anesthetic.
If you’re having a vacuum-assisted breast biopsy, your doctor will insert a tiny clip (a tissue marker) into the breast to pinpoint where the sample was removed so that it can be more easily found for follow-up testing or surgery.
Because more tissue is removed during a vacuum-assisted breast biopsy than during a core needle biopsy, the sample size of tissue is greater, which can lead to more accurate results. This can be useful if the tumor is very small and difficult to feel or palpate.
However, some patients may experience bleeding after the procedure and exercise is prohibited for about 24 hours after the procedure. Any bruising or pain that results is usually controllable with over-the-counter painkillers.
Lastly, surgical biopsies, also called excisional biopsies, are a more involved procedure that are less commonly used, Hawley says. They involve cutting out all or part of a lump and usually require local anesthesia.
“This is the last choice, as we would like to know the diagnosis before doing surgery,” Carpenter says. “In some cases, this is because we would use chemotherapy before surgery and in others, we would want to perform the correct procedure and not have to go back for a second procedure.”
But sometimes, a needle biopsy can’t be done because the person has a medical issue such as back pain or can't get into the optimal position for the doctor to reach the tumor, Carpenter explains, so an excisional biopsy may be performed instead. “In some cases, a core biopsy has already been performed and the result was either not enough, or worrisome or precancerous and then a surgical excisional biopsy is needed.”
Once the lump, or a section of the lump, has been removed, the incision will be sewn up and the tissue sent to the lab for testing. These biopsies nearly always leave a scar, which can be problematic for some patients. “When you’re having surgical biopsy, there’s a lot of disadvantages to that,” Hawley says.
Although surgical biopsy was once considered the gold standard, newer equipment and techniques have made it a less desirable option, in part because it’s surgery that requires anesthesia, operating room time and sometimes a short stay in the hospital. The other biopsy approaches “are outpatient procedures. You come in and you’re gone within an hour or two. So it’s a lot easier and more convenient to do it this way,” Hawley says.
Lymph Node Biopsies
If you’ve received a diagnosis of breast cancer, you may also undergo a lymph node biopsy procedure to determine whether that breast cancer has spread to the lymph nodes. Lymph nodes are small immune system structures located throughout the body.
In terms of breast cancer, your doctor will be most interested in checking the lymph nodes in the armpit to see if breast cancer cells have migrated there. Breast cancer cells typically show up in those axillary lymph nodes first once they’ve spread beyond the original cancerous tumor.
“This type of ‘biopsy’ is not really for diagnosing breast cancer, but rather for staging a known cancer,” which means determining how far along the cancer is, says Dr. Meghan Flanagan, a breast cancer surgical oncologist with Seattle Cancer Care Alliance and assistant professor of surgery at the University of Washington. “It is inherently a diagnostic procedure, but is not the same as the previous three.”
For this procedure, the doctor will inject “radioactive, colored dyes into the breast and allow them to travel up to the lymph nodes,” Flanagan explains. These dyes highlight cancerous cells. “This will allow the doctor to identify lymph nodes where cancer may have spread so they can remove and test these lymph nodes."
Use of non-surgical biopsy approaches may allow your doctor to combine these surgical steps into one procedure (biopsy, lumpectomy and lymph node surgery) potentially reducing the number of surgeries you’ll have. As such, the use of surgical biopsies has dropped in recent years, but Hawley says they may be more common in outlying or smaller hospitals that don’t have access to newer equipment or techniques.
Imaging Technology Used in Biopsies
Hawley says most biopsies are conducted with the assistance of imaging technology such as ultrasound, mammography or magnetic resonance imaging, also known as an MRI, to help the doctor pinpoint the right location for extracting tissue to be tested.
The decision on what type of imagery is to be used depends on the specific needs of the patient and the location of the suspicious lump. For example, “when an abnormal area is seen best by mammogram or MRI, the vacuum biopsy attachment and core biopsy is performed,” Carpenter says.
If the ultrasound is used as the guide, then smaller cores are possible and this is usually because the area in question is easily seen and can be obtained with smaller cores. However, “if the area in question is closer to a blood vessel or other structures of concern, smaller core biopsy needles are used that can be controlled better,” she explains.
“The most common type we do is the ultrasound-guided biopsy,” Hawley says. “It’s probably the easiest on the patient.”
In this approach, the patient lies on their back during the procedure, as “this positioning is typically the easiest and most comfortable of the breast biopsies,” says Dr. Brandy Griffith, a breast imaging radiologist at the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital Solove and Richard J. Solove Research Institute in Columbus. Your doctor will use an ultrasound machine to create an image of the suspicious area and use that to decide where to extract tissue.
In some patients, the use of mammogram (and sometimes tomosynthesis, or 3-D mammography) can help guide the doctor’s needle or scalpel. This process, also called a stereotactic biopsy, is often used when the mass is not palpable, meaning it’s difficult to feel during a physical exam.
During a stereotactic biopsy, the doctor takes “pictures of the breast from different angles to triangulate and calculate where the lesion is. It allows us to figure out where it is in space,” Hawley says. This approach is often used with calcifications – small deposits of calcium in the breast that are typically benign but need to be checked, as “they don’t typically show up as well on ultrasound,” Hawley says.
This approach may also be used if the suspicious finding seen via mammogram can’t be identified with ultrasound, which can happen if the tissue is distorted or asymmetrical.
During this type of procedure, “patients lie on their stomach on a stereotactic biopsy table or they’re seated at a mammogram machine that has a biopsy device attached,” Griffith explains. “The breast to be biopsied is placed in compression, as you would with a typical mammogram, for the entire procedure. This keeps the breast still so that we can see the lesion and perform the biopsy.”
Lastly, MRI may be used to help guide the biopsy in some rarer cases. This procedure is “a little more involved,” Hawley says because it requires the use of an intravenous, or IV, line into a vein to inject contrast dye that helps create the image. Lying inside noisy MRI machines can be distressing to people with claustrophobia, and it’s an expensive procedure.
In this approach, “patients lie on their stomach and the breast to be biopsied is placed in compression to hold the breast still during the procedure,” Griffith says.
MRI is a very sensitive tool that can pick up small lesions that would be missed on ultrasound or mammogram. Therefore, “we usually reserve it for high-risk populations,” Hawley says.
Which Type of Biopsy Will I Get?
The determination of which patient gets which type of biopsy depends on a number of factors including the size and location of the suspicious area, as well as any underlying medical conditions the patient may have, Flanagan says.
“It’s important to have a discussion with your health care provider to determine the best approach," Flanagan says. "It’s also important to have regular screenings and discuss individual health and family history with your health provider to determine the best approach” if breast cancer is diagnosed.
It’ll Be Over Quickly
No matter which type of biopsy is performed, “the portion of the procedure when the actual sampling is performed is the fastest part of the procedure,” Griffith says. “Typically, all of the steps that must be done prior to and after the procedure are what make up the majority of your appointment time.”
And it shouldn’t hurt, she adds. “Local numbing medication is used at the area in the breast where the biopsy is to be performed. Our goal is that you only feel pressure and movement in your breast during the procedure.”
Flanagan notes that “undergoing a breast biopsy can be a frightening experience for anyone, and it’s important to have the right care team that can help develop a comprehensive, personalized plan when needed.”
Updated on Jan. 14, 2022: This story was previously published at an earlier date and has been updated with new information.
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Michele Carpenter, MD
Carpenter is the breast program director at the Center for Cancer Prevention and Treatment at Providence St. Joseph Hospital in Orange, California.
Meghan R. Flanagan, MD, MPH, FACS
Flanagan is a breast cancer surgical oncologist with Seattle Cancer Care Alliance and assistant professor of surgery at the University of Washington.
Brandy Griffith, DO
Griffith is a breast imaging radiologist at the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital Solove and Richard J. Solove Research Institute in Columbus.
Jeffrey Hawley, MD
Hawley is a breast imaging radiologist with the Ohio State University Wexner Medical Center in Columbus.
Posted in: In Treatment, Just Diagnosed, Medical/Science