General Information
Breast biopsies are performed when imaging studies reveal lesions that are suspicious for carcinoma. If you haven't already, go check out my post on breast imaging studies for more details on the process and how radiologists evaluate lesions in the breast and determine whether they are benign or cancerous!
In addition to cancer, benign breast disease (such as fibrocystic changes, fibroadenomas or intraductal papillomas) can have a suspicious appearance on ultrasound or mammography. These lesions are biopsied to rule out the presence of any more sinister disease. Discussion between pathology and radiology important to help insure that targeted radiological abnormality has been sampled. Findings from core needle biopsies must be correlated with pre biopsy imaging findings to help ascertain concordance. With good pathologic and radiologic correlation, the likelihood of missed clinically significant carcinoma is small (< 5%).
Hints that you should look for a higher grade lesion
ADH is often present adjacent to DCIS; excisions yield DCIS in ~ 15% of cases
Papillomas with atypia: Associated with carcinoma on excision in 20-60% of cases
Routine excision of other types of BBD on core needle biopsy is debated
Incidental ALH or LCIS is rarely associated with carcinomas on excision (< 5%) and carcinomas found are generally very small and low grade
Excision is indicated when sufficient risk of adjacent DCIS or invasive carcinoma.
TRICKY SITUATIONS THAT MAY REQUIRE a pathologist's comment
Clinical history of a breast mass, but only normal (non-mass-like) breast tissue present:
COMMENT: “Histologic evaluation shows benign breast tissue without significant histopathologic abnormalities. Clinical correlation is required to ensure that the target area was properly sampled.”
Only fat is present (no glandular breast tissue):
COMMENT: “Histologic examination shows the presence of only benign fibroadipose tissue without breast parenchyma identified. These findings indicate that the mass may be a mesenchymal lesion (such as a lipoma). However, clinical correlation is required to ensure that the target area was properly sampled.”
Biopsy performed for microcalcifications, but you can’t find any:
NOTE: It is good practice for the clinician/radiologist to take the biopsy and then have both the paient AND the biopsy specimen sent for Xray/imaging before sending the specimen to pathology. This helps ensure that the suspicious area was biopsied; There should be a reduction in or no residual calcifications present in the patient. The specimen radiograph should demonstrate microcalcifications are present in the tissue.
NOTE: Calcium oxalate (10% of biopsies for microCa) cannot be detected on H&E. They require polarized light to identify their birefringent crystals.
COMMENT: “Multiple additional (deeper) levels were examined and correlation with the specimen radiograph was performed. No microcalcifications are identified within the entirely submitted tissue sections.”
Papillary Lesions:
COMMENT: “A focal papillary carcinoma cannot be excluded with complete certainty in this material. Excision or close surveillance recommended.”