Breast health

Breast biopsy

While a mammogram can show abnormal changes in breast tissue, only a breast biopsy can determine whether such changes are malignant (cancerous). A biopsy involves removing all or part of the abnormal tissue and sending it to a laboratory for analysis.

Not so long ago, biopsy and mastectomy were done as a single procedure: the biopsy was performed while the patient was under general anesthetic, and the tissue removed was immediately sent away for examination. The patient was kept under general anesthesia until the pathology reports were received. If a breast abnormality turned out to be breast cancer, a mastectomy was performed. Nowadays, unless a patient is too ill to undergo repeated anesthetic or surgery, biopsy and mastectomy are not generally performed as a one-step procedure.¹

Types of breast biopsy

There are several types of breast biopsy, and naturally, the choice of technique depends on the size, location, and characteristics of the lump. In addition, the type of biopsy performed also depends on whether the lump is palpable (can be felt externally by the patient or her physician on manual examination of the breast).²

Open incision biopsy

Taking about one hour and done regardless whether a lump is palpable, an open incision biopsy is typically done under local anesthetic: the area to be biopsied is numbed with a local anesthetic, and a sedative is administered as well. An incision of about 1 to 2 inches long (2.5 to 5 cm) is made as close to the lump as possible, and the surgeon then removes a piece of tissue, or, if the lump is small enough, the entire lump. The incision is then stitched closed.³

Where a breast lump cannot be felt, it must be located through a process known as needle localization. This renders biopsy somewhat more complicated and time consuming. The patient is sent to radiology to have a mammogram. The mammogram is used to pinpoint the lump; its location is marked by means of a wire needle inserted into the breast. The wire is then left inside the breast and taped to the skin. Once this is done, the patient is then taken to the operating room to undergo breast biopsy.⁴

Axillary node dissection

Performed under general anesthetic at the same time as a lumpectomy or a mastectomy or following a positive open incision biopsy, an axillary node dissection is done to determine whether breast cancer has metastasized (spread) beyond the breast. A procedure which commonly lasts between 1 and 2 hours, axillary node dissection involves looking for cancer cells in the axillary lymph nodes located under the arm. The surgeon makes an incision under the arm and removes a pad of fat in which are embedded 10 to 20 lymph nodes. The presence of cancer cells in the axillary lymph nodes may suggest that breast cancer has spread to other areas of the body and that the patient requires more aggressive cancer treatment. The results of axillary node dissection, then, help the patient and her doctor determine the best course of cancer therapy.⁵

Sentinel node biopsy

Less invasive than axillary node dissection, sentinel node biopsy involves the removal and analysis of the sentinel node. This procedure is built around the assumption that the sentinel node is the first lymph node to filter fluid from the breast. Many oncologists and cancer experts believe breast cancer cells reach the sentinel node first and that as such, the sentinel node is more likely to contain malignant cells. What?s more, if the sentinel node is free of cancer cells, it's highly likely that the other nodes are also free of cancer. Combined with lumpectomy, sentinel node biopsy is easily performed as an outpatient procedure and causes less pain and deformity than axillary node dissection. (See complications, below.)⁶

Once the patient has been given a general anesthetic, a radioactive tracer and a blue dye are injected into and around the tumor. Using a small, hand-held Geiger counter, the surgeon tracks the path of the tracer as it travels from the breast and under the arm to the sentinel lymph node. Once located, the sentinel node is then removed and sent away for analysis. As explained, if the results of sentinel node biopsy are negative, further surgery isn't needed. However, if the results are positive, the surgeon may perform an axillary node dissection in order to determine how many of the other lymph nodes are affected.⁷

Needle aspiration

Less invasive and quicker than axillary node dissection, needle aspiration uses a needle to draw out fluid or tissue from a breast lump. This procedure normally leaves no scarring and does not typically require stitches or a long recovery period. There are various types of needle aspiration (e.g., fine needle aspiration, core needle biopsy, vacuum-assisted biopsy, and large core biopsy; see Oncology Channel for more information) and each procedure differs in how it is performed, the type of equipment used, the type of lump or lesion on which it's most effective, and the amount of tissue it's designed to remove. Though less invasive than surgical techniques, you should know that needle aspiration cannot remove an entire lesion, and it is possible for misdiagnosis to occur.

What to expect

Open incision biopsy

Usually performed on an outpatient basis, open incision biopsy requires that you sign an informed consent form. The surgeon will explain to you any risks associated with the procedure. If you are taking any anticoagulant medication (e.g. aspirin), be sure to mention it to your doctor as soon as the decision to do the biopsy is made; it's common for blood thinners to be discontinued for several days prior to surgery to avoid abnormal bleeding. You may receive a sedative intravenously or by injection.⁸

For 1 to 2 weeks following surgery, be sure to avoid any heavy lifting. For 2 to 3 weeks, avoid any strenuous activity. Be sure to keep your stitches dry to prevent infection; your doctor may recommend sponge baths until the stitches are removed—usually within 7 to 10 days following your biopsy. Your incision will completely heal in about a month or so and will leave a small scar that will fade in time.⁹

Axillary node dissection

A few days before your surgery, your doctor will send you for a series of tests in order to determine your overall health. While these tests vary according to a patient's health and age, they generally include a blood test, a chest x-ray, and possibly an electrocardiogram (EKG). If you've had these tests recently, they don't need to be repeated. If you are taking any anticoagulant medication, be sure to mention it to your doctor as soon as the decision to do the biopsy has been made; it's common for blood thinners to be discontinued for several days prior to surgery to avoid excessive bleeding during the operation.¹⁰

Because axillary node dissection is performed under general anesthetic, you will be instructed not to eat or drink anything for at least 8 hours before your operation. When you arrive at the hospital, you will be asked to sign an informed consent form, and you doctor will answer any last-minute questions you might have. He or she will also explain any risks associated with your operation. You will then receive anesthesia and any necessary medications. A nurse will begin an intravenous line to administer fluids and medication you may need during your surgery. You may also receive a sedative. The anesthesiologist will then perform a brief medical examination, take your medical history, and ask about any medications you are currently taking, any allergies you have, and any adverse reactions to anesthesia. The information you provide will help assess any problems or conditions that may affect the choice of anesthesia, and it will also help the surgical team determine whether any special precautions need to be taken.¹¹

After surgery, you'll be taken to a recovery area and closely monitored by nursing staff until the effects of the anesthesia wear off. Once you fully wake up and your vital signs are stable, you'll be taken back to your hospital room. Your IV line will remain in place until you are able to take clear liquids orally—most patients are able to eat and drink soon after they wake up from surgery. Unless you are receiving antibiotics intravenously, the nurse will remove your IV line at this time. Once the effects of the anesthesia have worn off, you will feel pain around the incision site; your doctor will prescribe pain medication. You can expect to stay in the hospital overnight—longer if complications develop.¹²

You can expect that your recovery will last about 6 weeks. During this time, avoid strenuous activity and heavy lifting. You may also experience a loss of sensation under the arm caused by the nerves' being cut during surgery. For some patients, this loss of sensation is permanent. You may also notice an indentation in your armpit where fat was removed. This may be accompanied by sore muscles, tightness in the arm, and difficulty moving the arm. These annoyances can be alleviated through stretching and range of motion exercises; be sure to begin these as soon as your doctor says you are well enough. It may take longer than 6 weeks for your affected arm to regain its strength and normal range of motion. A physical therapist or other health practitioner can set up an exercise program to help you increase arm movement.¹³

The drain and stitches are removed during your first follow-up visit. Be sure you keep this area dry—your doctor may recommend sponge baths. Also avoid using deodorant on the incision site until healing is well underway.¹⁴

Sentinel node biopsy

Because axillary node dissection is performed under general anesthetic, you will be instructed not to eat or drink anything for at least 8 hours before your operation. When you arrive at the hospital, you will be asked to sign an informed consent form, and you doctor will answer any last-minute questions you might have and will also explain any risks associated with your operation. You will then receive anesthesia and any necessary medications. A nurse will begin an intravenous line to administer fluids and medication you may need during your surgery. You may also receive a sedative. The anesthesiologist will then perform a brief medical examination, take your medical history, and ask about any medications you are currently taking, any allergies you have, and any adverse reactions to anesthesia. The anesthesiologist will also need to make sure you don't have an allergy to the blue dye used in the procedure. The information you provide will help assess any problems or conditions that may affect the choice of anesthesia and will also help the surgical team determine whether any special precautions need to be taken.¹⁵

Because fewer lymph nodes are removed than during axillary node dissection, patients undergoing sentinel node biopsy typically have few, if any, side effects. You may notice that the blue dye gives your breast a bluish color. The radioactive material used in the procedure will remain in your system for a short time, usually between 24 and 48 hours. Some of this material is expelled in the stool or urine, and you may notice that your urine may turn green for about 24 hours.¹⁶

Needle aspiration

Performed in doctors' offices, clinics, surgical centers, and hospitals, the type of needle aspiration performed depends on the technique selected, equipment available, the patient's health, and the doctor's preference. There is little preparation needed, aside from signing an informed consent form and ensuring your doctor has made you aware of the potential risks. Sedative isn't usually required, although local anesthesia is administered through a series of several injections. Recovery is generally uncomplicated and quick, with most patients able to resume normal activity almost immediately. Pain is minimal and can usually be managed with a non-prescription pain reliever. During the first week following the biopsy, large core and vacuum-assisted procedures may cause bruising on the breast. This bruising is temporary and may be alleviated using an ice or cold pack. Swelling may also occur with the vacuum-assisted method. Stitches used to close the incision made in large core biopsy are generally removed within 7 to 10 days following surgery.¹⁷

Possible complications

Open incision biopsy

Although infection can occur and the incision should be watched for redness, swelling, or fluid leakage—all of which should be immediately reported to your doctor—there are few complications associated with open incision biopsy.¹⁸

Axillary node dissection

The most common complications associated with axillary node dissection include:

• permanent numbness under the arm
• swelling of the arm caused by scarring of the lymph vessels
(this occurs in fewer than 12 percent of cases)
• infection of the incision site

Increase in pain, drainage, swelling, or redness at the incision site may all indicate infection and should be immediately reported to your doctor.

Because axillary node dissection removes many of the lymph nodes that protect against infection, you may notice that the arm and hand on the affected side may become more susceptible. Blood should not be drawn from this arm, and any minor injuries should be reported to your doctor who will also want to check your arm and hand regularly for inflammation or cuts.¹⁹

Sentinel node biopsy

Sentinel node biopsy carries fewer complications than axillary node biopsy.

Needle aspiration

Although complications from needle aspiration are rare, excessive swelling, redness, bleeding, or other draining can indicate infection or abnormal bleeding and should be reported to a doctor immediately.²⁰

You should note that all surgery causes internal scarring and that scar tissue can interfere with readings of future mammograms. Be sure to discuss any questions or concerns you might have about biopsy with your doctor. He or she should be willing to talk to you about the benefits, risks, and limitations of biopsy.

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