Breast lumps other diagnostic studies

The only certain method to approve the presence of breast malignancy is breast lump biopsy.The three types of biopsies are core-needle biopsy, open surgical biopsy, and fine needle biopsy. Core-needle biopsy has different types such as ultrasound guided-core needle biopsy, stereotactic-guided core-needle biopsy, MRI-guided core-needle biopsy, and freehand core-needle biopsy. Core-needle biopsy has high sensitivity and specificity. Triple test score is used by surgeons for assessment of palpable breast lumps. Classic type of triple test includes clinical breast examination, FNA, and mammography and modified version includes clinical breast examination, core-needle biopsy and ultrasound.

The only certain method to approve the presence of breast malignancy is breast lump biopsy.^[1]

There are three types of biopsy:

• Core-needle biopsy
• Open surgical biopsy
• Fine needle biopsy^[2]

Core-needle biopsy:^[1]

• Ultrasound guided-core needle biopsy:^[3]
  • The needle is guided by use of ultrasound and patient lies on back or side
  • Highly sensitivity and specificity
  • Choice method for breast tissue sampling
• Stereotactic-guided core-needle biopsy
  • The needle is guided by use of x-ray and computer and patient lie on stomach.
  • Choice method for mammograohically suspicious breast lumps which are occult in ultrasound.^[4]
• MRI-guided core-needle biopsy
  • The needle is guided by Magnetic resonance imaging.
• Freehand core-needle biopsy
  • Usually used for breast lumps which can be felt by hand on breast tissue.

Core-needle biopsy has lower risk of complications such as bleeding, bruising and infection

Open surgical biopsy:^[1]

• Perform under general anesthesia
• If core-needle biopsy is unavailable due to location of breast lump, open surgical biopsy is required
• In patients with high risk of cancer is recommended
• 1-2 inch cut on breast tissue for breast lump removal
• Higher risk of complications (bruising, bleeding, pain and infection)

Fine needle biopsy (FNA):^[2]

• Performed by small needle (21-25 gauge)
• Regarding to small amount of breast tissue, FNA is considered as controversial method for breast lump diagnosis
• Performed for large and symptomatic breast cysts or imaginary abnormalities
• Complications of FNA include bruising, bleeding, pain, infection and pneumothorax; if needle goes deep inside the chest)
• Due to inadequate tissue or nondiagnostic results, FNA has lower rate of diagnosis rather than core-needle biopsy
• FNA advantages:
  • Cost-effectiveness
  • Less invasive method
  • Suitable for patient under anticoagulant therapy
  • Appropriate to sample axillary tissue
• FNA follow-up:
  • Non-bloody fluid/resolved cyst
    • Ultrasound follow-up to reassure the cyst has been resolved
    • No more follow-up
  • Bloody fluid/ persistent cyst
    • Refer to a surgeon for open surgical biopsy

Triple test score is used by surgeons for assessment of palpable breast lumps:^[5][6]

• Classic triple test:
  • Clinical breast examination, FNA and mammography
• Modified version of triple test
  • Clinical breast examination, Core-needle biopsy and ultrasound
• Palpation, mammography and biopsy are required for women aged > 35 years^[7]
  • If mammography is negative, biopsy is needed to rule out malignancy especially lobular carcinoma
• Palpation, ultrasound and biopsy are suggested for women <35 years
  • Surgeons may omit biopsy for fibroadenoma features on ultrasound and prefer 6 month follow-up for 2 years
  • Some surgeons recommend core-needle biopsy or FNA for all fibroadenomas
    • Particularly in carriers of BRCA mutation
    • Reduce the need for serial ultrasound

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