Tissue Sampling Options Lisa A. Newman, M.D., M.P.H., F.A.C.S. Professor of Surgery Director, Breast Care Center University of Michigan Ann Arbor, MI

Breast Masses/Abnormalities Palpable or Non-Palpable (screen-detected) Benign or Cancerous –Benign: Cyst; Fibroadenoma; Fibrocystic Density but not always!Breast imaging (mammo and sono) can identify the benign masses frequently, but not always! ALWAYSBiopsy is ALWAYS necessary to document cancer, and is frequently necessary to confirm benign lesions Whenever possible, needle biopsies are preferred as the first step in diagnosing a breast mass

Considerations when Choosing Biopsy Technique Available resources –Surgical services –Technology; biopsy devices –Pathology interpretive services Goal of biopsy material –Establish diagnosis –For cancers, must have adequate tissue for therapeutic marker informatioin ER; PR; HER2/neu –Research/tissue banking?

Considerations when Choosing Biopsy Technique Biopsy result MUST be concordant with clinical impression –If not, then additional sampling and/or additional pathoology review is necessary –Patient follow-up is essential!!!! Multidisciplinary management of breast lesions involves pathology –Must plan biopsy program with path based on local resources and expertise

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Open, excisional biopsy (gold standard) Open, incisional biopsy Percutaneous, free-hand needle biopsy –Fine-needle aspirate (FNA) –Core, Tru-Cut needle biopsy Image-directed needle biopsy –Ultrasound-guided –Stereotactic/mammo-guided

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Open, excisional biopsy (gold standard) vs. Open, incisional biopsy Both require use of surgical services Excisional implies complete removal of mass Incisional useful with large, bulky lesions –Advantageous in pts receiving neoadjuvant chemotherapy Either approach provides substantial amounts of tissue for diagnosis, molecular marker analyses

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Percutaneous, free-hand needle biopsy –Fine-needle aspirate (FNA) –Core, Tru-Cut needle biopsy FNA: readily-available small-guage needles can obtain material for cytologic analyses –No tissue wedge available and therefore cannot reliably distinguish invasive from in situ disease –Very useful for evaluation of bulky lymph nodes –Requires additional cytopathologic expertise for appropriate interpretation –Requires additional pathology expertise in order to obtain molecular marker information (ER/PR/HER2)

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Percutaneous, free-hand needle biopsy –Fine-needle aspirate (FNA) –Core, Tru-Cut needle biopsy FNA: readily-available small-guage needles can obtain material for cytologic analyses (22-26 G) –Easily-tolerated by patient –No tissue wedge available and therefore cannot reliably distinguish invasive from in situ disease –Requires additional cytopathologic expertise for appropriate interpretation –Preferable to have special storage solution for specimen transport and processing –Requires additional pathology expertise in order to obtain molecular marker information (ER/PR/HER2)

Fine Needle Aspiration Biopsy

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Percutaneous, free-hand needle biopsy –Fine-needle aspirate (FNA) –Core, Tru-Cut needle biopsy Core needle biopsy: commercially-available, spring- loaded needle biopsy devices (14-18 Guage; 10 or 20 mm length cores of tissue extracted) –Requires local anesthetic; multiple passes –Specimen cores placed in formalin solution for transport and processing –Adequate tissue for full histopath architecture evaluation and molecular marker studies –Adequate tissue for tumor banking

KATH-UM Breast Cancer Collaboration Core Needle Biopsies at KATH Prior to summer 2008: majority of breast tumors at KATH evaluated by either surgical biopsy or FNA biopsy –KATH staff concerned about inefficient use of surgical resources and tissue adequacy with FNA biopsies July 2008: Training course implemented

UM-Ghana Collaboration: Academic Exchange

KATH-UM Breast Cancer Collaboration Core Needle Biopsies at KATH : UM and KATH teams work in clinic together to evaluate breast masses July 2008: Training course implemented Since training course implemented, KATH pathology available on 82 core biopsy specimens –UM path review on malignant 46 cores, all confirming cancer –UM path review on 10 benign cores, all concordant by UM review (mostly fibroadenoma diagnosis)

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Open, excisional biopsy (gold standard) Open, incisional biopsy Percutaneous, free-hand needle biopsy –Fine-needle aspirate (FNA) –Core, Tru-Cut needle biopsy Image-directed needle biopsy –Ultrasound-guided –Stereotactic/mammo-guided –Can minimize risk of sampling error/false-negative result –Requires mammography and ultrasound equipment; radiology expertise

H ISTOPATHOLOGIC W ORK -U P OF P ALPABLE M ASSES Open, excisional biopsy (gold standard) Open, incisional biopsy Percutaneous, free-hand needle biopsy –Fine-needle aspirate (FNA) –Core, Tru-Cut needle biopsy Image-directed needle biopsy –Ultrasound-guided –Stereotactic/mammo-guided Punch Biopsy Device: Circular scalpel –Classically utilized by dermatologists –Easy-to-perform, office-based procedure under local anesthesia –Useful for breast lesions involving skin –3; 4; and 6 mm punch biopsy devices available –Will usually require suture to close remaining skin defect

Wire localization surgical biopsy for mammographically-detected breast lesion

Summary Multiple biopsy options are available Surgical resection is gold standard for complete histopathologic evaluation Percutaneous needle biopsies are efficient and spare surgical rescources Punch biopsies useful for ulcerated lesions involving skin Multidisciplinary management of breast lesions involves pathology –Must plan biopsy program with path based on local resources and expertise CONCORDANCE is critical!!!! –Hand-in-hand with patient follow-up

THANK YOU!!!!!!!