Edelweiss - Types of Breast Biopsies and Excisions Edelweisshoustonpathologists.org/Edelweiss - HSCP...

57th HSCP Advocate Seminar 4/16/16

Marcia Edelweiss, MD 1

Types of Breast Biopsies and Excisions

Marcia Edelweiss MDAssistant Attending Pathologist

Faculty Disclosure

Marcia Edelweiss MD

I have no financial interest/arrangement that would be considered a conflict of interest

High Risk Lesions on Percutaneous image‐guided breast core biopsy

• A biopsy is a small tissue sample that is removed for the diagnosis of a lump or area of calcifications before a definitive procedure is indicated

• An excision is a surgical procedure that removes more breast tissue and has both diagnostic and treatment purposes.

What is the main difference between a biopsy and an excision?



Types of Biopsies and Excisions

Biopsies

• Fine needle Aspiration (FNA)

• Core needle biopsy (CNB)– Stereotactic

– Vacuum‐assisted

– Ultrasound guided

– MRI guided

Excisions

• Local excision (breast conserving surgery, lumpectomy, partial mastectomy) with or without separate margins

• Mastectomy (simple, modified radical, radical)

• Sentinel lymph node (with local excision or mastectomy)

• Axillary dissection (with local excision or mastectomy)

What type of biopsy is needed?

The choice of which type to use depends on things like how suspicious the radiological image looks, how big it is, where it is in the breast, how many tumors there are, and if any other medical problems are present.


Biopsies





– MRI guided

Excisions







FNA

7

FNA

8

Material may be collected in a variety of media (CytoLyt, SurePath, Formalin, RPMI, etc)

PAP

TP

Cell block

DQ

Unfixed (fresh)1

Air‐dried, Diff‐Quik (Wright‐Giemsa)‐ stained smears

EtOH‐fixed, Papanicolaou (PAP)‐stained smears

Liquid based (ThinPrepTM, Hologic;SurePathTM, BD Diagnostics)

Cell block(paraffin‐embedded)

FNA Slide Preparation



Who performs the FNA and how does it work?

• It can be performed by the pathologist, radiologist, or surgeon in the office and uses a very thin needle attached to a syringe to aspirate cells from the suspicious area.

• The needle used for FNA is thinner than the ones used for blood tests.

• If the area to be biopsied can be felt, the doctor locates the lump or suspicious area and guides the needle there. If the lump can’t be felt, ultrasound might be used to watch the needle on a screen as it moves toward and into the mass.

• The doctor may or may not use local anesthetic to numb the area.

• Once the needle is in place, fluid or tissue is drawn out. If clear fluid is withdrawn, the lump is more likely a benign cyst (not cancer). Bloody or cloudy fluid can mean either a benign cyst or, less often, cancer. If the lump is solid, small pieces of tissue are drawn out.

• A pathologist will look at the biopsy tissue or fluid under a microscope to find out if there are cancer cells in it.

Current uses of FNA in Breast Pathology

• For first time diagnosis: Late 90’s‐now ↓

• Palpable masses: CNB or FNA ? (institution dependent)

• Non palpable masses/calcifications: CNB

Current uses of Breast FNA

•Primary Diagnosis:

•FNAs of the breast usually used when there is eitherextremely low or extremely high suspicion in a palpablemass (but it will always be confirmed with a core biopsy,with few rare exceptions)

•Cancer staging and management purposes:

•In preop evaluation of clinically suspicious lymph nodes

•In evaluation of metastatic sites or local recurrences(breast implant)



Trend of Breast FNAs at MSKCC

13

Few Reasons for ↓ FNA Popularity for first time diagnosis

• Inability to distinguish In situ from invasive carcinoma

• More limited specimen or inadequate samples for ancillary studies upfront (i.e. ER/PR and Her2)

• Requires strict correlation with clinical and radiological impression for correct diagnosis

• Better core biopsy devices and experience

• A fine needle aspiration biopsy can sometimes miss cancer if the needle doesn’t get a tissue sample from the area of cancer cells. If it doesn’t give a clear diagnosis, or there is still concern, a second biopsy or a different type of biopsy should be done.


Biopsies





– MRI guided

Excisions







Core Needle Biopsy

• A core needle biopsy (CNB) is a larger, hollow needle that is used to withdraw small cylinders (or cores) of tissue from the abnormal area in the breast.

• A CNB is most often done in radiology suite with local anesthesia. The needle is put in 3 to 6 times to get the samples, or cores. This takes longer than an FNA, but it’s more likely to give a clear result because more tissue is taken to be checked.

• The provider doing the CNB usually places the needle in the abnormal area using ultrasound or x‐rays to guide the needle into the right place. If the area is easily felt, the biopsy needle may be guided into the tumor while feeling (palpating) the lump.

Examples of CNB Devices

17

Core biopsy

18



Core Biopsy

19

Core biopsy

20

Core Biopsy

21



Stereotactic Core Needle Biopsy

• A stereotactic core needle biopsy uses x‐ray equipment and a computer to analyze pictures of the breast. The computer then pinpoints exactly where in the abnormal area the needle tip needs to go. This is often done to biopsy suspicious microcalcifications (tiny calcium deposits) when a tumor can’t be felt or seen on ultrasound.

22

MAMMOGRAPHICCa2+

Vacuum‐assisted Core Biopsy

• Vacuum‐assisted biopsies can be done with special biopsy systems. For these procedures, the skin is numbed and a small cut (less than ¼ inch) is made. A hollow probe is put in through the cut and guided into the abnormal area of breast tissue using x‐rays, ultrasound, or MRI. Tissue is then pulled into the probe through a hole in its side, and a rotating knife inside the probe cuts the tissue sample from the rest of the breast.

• These methods allow multiple tissue samples to be removed through one small opening.

• They are also able to remove more tissue than a standard core biopsy (because of applied vaccum).

• Vacuum‐assisted core biopsies are done in outpatient settings.

24



Ultrasound Guided Core Needle Biopsy

• Ultrasound might be used to watch the needle on a screen as it moves toward and into the mass.

25

Magnetic Resonance Imaging (MRI) Guided biopsy

• Sometimes the biopsy is guided by MRI. The patient lays face down on a special table with an opening that breast fits into. Computers are then used to find the tumor, plot its location, and help aim the probe into the tumor. This is helpful for women with a suspicious area that can only be found by MRI.

26

• After the radiologist has taken out all of the tissue samples needed, a very small, safe marker or clip may be put in your breast at the biopsy site. These clips are tiny, surgical‐grade, metal devices that show up on mammograms and are used to mark the biopsy site. The clip can’t be felt and should not cause any problems. It’s used to mark the area in case changes show up on future mammograms.

• I125 radioactive seed localization can also be placed at the time of the biopsy so wire localization for surgery is not necessary

27

Biopsy markers



Once glass slides are prepared and ready:

The pathologist needs to know the nature of CNB target

• mammographic Ca2+

• mass lesion

• architectural distortion

• MRI abnormality

–mass‐like

– enhancement

http://www.elswood.eu/images/stories/pdf/Breast_Biopsy_A_Pathologists_Perspective_on_Biopsy_Acquisition_Techniques_and_Devices_with.pdf

Part of the job of the pathologist:

• Clinical and radiological correlation

– Do the CNB findings explain the radiology/clinical findings?

– Radiologist responsible for final rad‐path correlation, but pathologist also has critical role

CNB for Ca2+

• We always receive the cbx specimen X‐ray

• The radiologist identifies and separates the cores with Ca2+



Microcalcifications (Ca2+ oxalate)

• “broken glass”, translucent and refractile

• refringent under polarized light

• NOT associated with carcinoma

Microcalcifications (Ca2+ phosphate)

X‐ray of tissue blocks




Biopsies





– MRI guided

Excisions





Local Excision (Breast Conserving Surgery)

• The local excision removes the entire tumor or abnormal area, with or without trying to take out an edge of normal breast tissue (it depends on the reason for the excisional biopsy).

• It is usually done in the hospital’s outpatient department.

• The surgeon may use a procedure called wire localization to do an open biopsy if there’s a small lump that’s hard to find by touch, or if an area looks suspicious on the mammogram but can’t be felt. For wire localization, the breast is numbed with a local anesthetic and a thin, hollow needle is put into the breast while x‐rays are used to guide it to the suspicious area. A very thin wire is put in through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed, and the wire is left to guide the surgeon to the abnormal area.

• If a radioactive seed was used in the prior biopsy the wire is not necessary.

35

Excision of mass / lesion

Needle‐wire localization

– One wire: lesion is near the thick part of the needle (not near the tip!)

– Two wires: area of interest is between thick part of wires



Excision of mass / lesion

I125 Radioactive seed localization – One seed: lesion is near the seed

– Two seeds:

• two separate masses

• area of calcifications between the two seeds

Radioactive seed

Radiology clip

39



Radial (=perpendicular) margin methodSpecimen received orientedShort stitch =

superior margin

Long stitch = lateral margin


Biopsies





– MRI guided

Excisions





Mastectomy

• Mastectomy is surgery to remove the entire breast.

• All of the breast tissue is removed, sometimes along with lymph nodes.

42



Types of Mastectomy

• Simple Mastectomy (total mastectomy)

• Double Mastectomy

• Skin Sparing Mastectomy

• Nipple Sparing Mastectomy

• Modified Radical Mastectomy

• Radical Mastectomy

43

Simple (or total) mastectomy

• Most common type of mastectomy used to treat breast cancer.

• Entire breast is removed, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast. (Sometimes lymph nodes are removed in a different procedure during the same surgery.)

Double mastectomy

• Mastectomy is done on both breasts

• Often done as preventive surgery for women at very high risk for getting cancer in the other breast.

44

Skin‐sparing mastectomy

• Most of the skin over the breast (other than the nipple and areola) is left intact.• The amount of breast tissue removed is the same as with a simple mastectomy. • Skin‐sparing mastectomy is only used when immediate breast reconstruction is planned.

It may not be suitable for larger tumors or those that are close to the surface of the skin. Implants or tissue from other parts of the body are used to reconstruct the breast.

Nipple‐sparing mastectomy• Nipple‐sparing mastectomy is a variation of the skin‐sparing mastectomy• It is more often an option for women who have a small, early‐stage cancer near the outer

part of the breast, with no signs of cancer in the skin or near the nipple.• In this procedure, the breast tissue is removed, but the breast skin and nipple are left in

place. • This is followed by breast reconstruction. • The surgeon often removes the breast tissue beneath the nipple (and areola) during the

procedure to check for cancer cells and send it to a pathologist.• If cancer is found in this tissue, the nipple must be removed• There are still some problems with nipple‐sparing surgeries. Afterward, if the nipple does

not have a good blood supply, it may not be viable or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple.

45



Modified radical mastectomy• A modified radical mastectomy

combines a simple mastectomy with the removal of the lymph nodes under the arm (called an axillary lymph node dissection).

Radical mastectomy• In this extensive operation, the

surgeon removes the entire breast, axillary (underarm) lymph nodes, and the pectoral (chest wall) muscles under the breast. This surgery was once very common, but less extensive surgery (such as modified radical mastectomy) has been found to be just as effective and with fewer side effects, so this surgery is rarely done now. This operation may still be done for large tumors that are growing into the pectoral muscles.

46


Biopsies





– MRI guided

Excisions





Sentinel Lymph Node (SLN) and Axillary Dissection

• Sentinel Lymph Node:– Is a surgical procedure to determine if

cancer has spread to the lymphatic system in the axilla

– Sentinel node biopsy involves injecting a tracer material (blue dye and/or radioactive material) that helps the surgeon locate the sentinel nodes during surgery.

– A pathologist examines the sentinel lymph node under the microscope

– If the Sentinel Lymph Node(s) are positive for carcinoma: Patient may or may not get a complete removal of the lymph nodes for the axilla

– If the Sentinel Lymph Node(s) are negative for cancer: no additional surgery is necessary

• Axillary dissection:– Is the complete removal of the lymph

nodes from the axilla

48



MSKCC management of pts w/ T1‐T2 invasive carcinoma and clinically negative axillary LNs

Lumpectomy + whole breast irradiation

(ACOSOG Z11 study)

• NO SLN Frozen section

• Axillary dissection only if cancer is present in >3 SLNs

Mastectomy

• Frozen sections of SLNs

• If SLN(+) (=cancer detected on FS) immediate axillary LN dissection

Date post:	03-May-2020
Category:	Documents
Upload:	others
View:	3 times
Download:	0 times

Edelweiss - Types of Breast Biopsies and Excisions Edelweisshoustonpathologists.org/Edelweiss - HSCP...

Documents