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I need a biopsy? What are the different types of biopsies? Why choose one over the others? 

It really depends upon WHY the biopsy is being done. It is a decision that should be made by you and your surgeon after discussing your options. Your surgeon will know which biopsy to recommend in your particular situation. S/he may recommend something different than what your friend, or aunt, or neighbor had done, OK?


Types of biopsies, PROS and CONS of each:


Fine Needle Aspiration (FNA): done with a needle and syringe, with or without local anesthetic (DEMAND an anesthetic!! You have that right!)

PROS: one of the least invasive, it is cheap, quick, and easily done in the surgeon's office. May leave temporary minimal bruising. Leaves no scar. No recovery time.

CONS: not very reliable--it samples a small area, not the entire area. May have blood in the specimen, which obscures any important information needed. There are many tiny blood vessels that can be nicked with an FNA--may lead to bruising and a "non-diagnostic" specimen. That means no cancer cells can be seen through the blood. You may still worry.


Core biopsy: typically done by a radiologist or a surgeon. It may be a "stereotactic core" (done under mammographic guidance), "ultrasound-guided core" (done under ultrasound guidance), or done free-hand by a surgeon who can feel the lump. The skin is numbed with a local anesthetic and a small nick is made in the skin. A thin biopsy tool (resembling spaghetti) is inserted a few times and small 0.5cm plugs of tissue are sampled.  

PROS: One of the least invasive biopsies, leaves a minimal scar, resembling a nick. No stitches. Good for sampling an area of microcalcifications, or a suspected fibroadenoma (a benign lump). No recovery time to speak of--you can do your normal activities.

CONS: May not sample the correct areas--may miss an area of cancer if small. You will still need an excisional biopsy if it was done for calcifications that show cancerous changes. You may still worry.


Incisional biopsy: a surgical biopsy done under IV sedation and local anesthetic. Done as an outpatient procedure. An 1-2 inch incision is made. One or more pieces of a lump are removed, leaving the remainder intact.

PROS: If it is benign then less tissue was removed, perhaps leaving a better cosmetic result. If it is cancerous, no PROS that I can think of, sorry.

CONS:  surgical procedure, internal stitches & external steri-strips for 1 week. 1-2 inch scar (possibly larger) remains. If cancer is detected, an excisional biopsy needs to be done to remove the remainder of the lump. Recovery time approximately 1 week. More frequent follow-up may be required, depending upon your situation (ie mammograms or ultrasounds, exams by a specialist). You may still worry.


Excisional biopsy:  a surgical biopsy done under IV sedation and local anesthetic. Done as an outpatient procedure. An 1-2 inch (possibly larger) incision is made and the entire area of concern is removed.

PROS:  the entire area of concern is removed, usually. Peace of mind.

CONS: if there is cancer, it may have extended beyond the excised area & another "re-excision to clear margins" will be needed. Is a surgery. Has internal stitches & external steri-strips for 1 week. Leaves a scar. Recovery time approximately 1 week. If there was no cancer present, more tissue was removed than may have been necessary.


Some things to consider when making your decision:


For instance, if you have a small to medium sized lump an "excisional" biopsy may be best. An excisional biopsy removes the entire lump.


If it is a LARGE lump, you may have an excisional biopsy OR an "incisional" biopsy. An incisional biopsy will cut into the lump and remove a section of it (or a few sections of it) for testing.


If you have calcifications, you have a choice between a "core" biopsy (in which 1 or more plugs of tissue are taken from the area) or a "needle localization excisional biopsy," in which the surgeon is guided to the area and removes the entire area of concern.


My opinion on biopsies for calcifications: You may very well want to consider having a needle localization biopsy (also called a wire localization biopsy). The reason I say this, is in my experience that's the best way to get RID of those microcalcifications.


The stereotactic biopsy can only "sample" a few of them, whereas the excisional biopsy will get RID of the cluster they are concerned about.


If you choose a "core" biopsy: If it is benign, you are none the worse for wear except that you will most likely have to watch the area closely every 6 months. If it shows something, you need to have an excisional biopsy anyway.


An excisional biopsy is considered a surgery and done as an outpatient. It is typically done under IV sedation and local anesthetic (you are asleep, for all intents and purposes). Many times this is done with the assistance of a needle or wire localization. The needle/wire localization is done while you are awake.


Under mammography, a small area of your breast is numbed with local. A needle or wire is inserted into your breast just beyond the depth of the suspicious area. This tells the surgeon how far to go (many times a lump can't be visualized by the surgeon. Calcifications are too tiny to be seen by the surgeon.


The wire/needle is taped to your chest (to stabilize it) and you are taken to pre-op, where you receive your IV sedation. Then you go to the O.R.


The surgeon makes a small incision (about 1-2 inches, typically) and scoops out a small amount of tissue just beyond the wire (sort of like scooping out a piece of watermelon just beyond a seed).


While you are still on the table, the specimen is taken to x-ray to make sure the suspicious area is within the biopsy specimen. You are then stitched internally and steri strips (like a super surgical tape) are placed on the outside. The stitches will dissolve over time. The steri-strips will come off in about 7 days.


You go to recovery and wake up with a small bandage on your breast. You can pretty much do whichever activites you like. You will be a little tender for a couple of days but will get a prescription for pain medication to take home.




With an excisional biopsy, if it turns out to be benign, you have had the lump removed and won't have to just sit and "watch" it. If it turns out to be something, you have already taken care of it with this surgery.