What is the recommended biopsy method for breast microcalcifications?

Recommended Biopsy Method for Breast Microcalcifications

Stereotactic core-needle biopsy is the recommended initial approach for sampling suspicious breast microcalcifications, with image-directed open surgical biopsy as the alternative when stereotactic biopsy is not feasible. 1, 2

Primary Biopsy Approach

• Stereotactic core-needle biopsy performed by qualified radiologists, surgeons, or other physicians is the initial recommended approach for sampling suspicious nonpalpable mammographic microcalcifications 3, 1
• Multiple cores should be obtained during the procedure to ensure adequate sampling of the calcifications 3, 2
• Specimen radiography should be performed to confirm adequate sampling of the microcalcifications 2
• Leaving some microcalcifications at the site is desirable to facilitate future localization if DCIS is diagnosed 3
• A marker should be left at the biopsy site if all microcalcifications are removed 1

When Stereotactic Biopsy May Not Be Appropriate

Not all patients with microcalcifications are ideal candidates for stereotactic biopsy. Image-directed open surgical biopsy is the preferred approach when:

• The patient's breasts are too small to be accommodated by the stereotactic system 3, 1
• The breast thickness is inadequate to allow the full throw of the automated biopsy device 3
• Calcifications are located just under the skin or very posteriorly 1
• Calcifications are widely separated, making stereotactic coordinates difficult to generate 3
• Individual microcalcifications are not well visualized due to limitations in the stereotactic imaging system 3
• The patient is uncooperative 3

Guided Wire Open Biopsy Technique

When stereotactic biopsy is not feasible, image-directed open surgical biopsy should be performed:

• Nonpalpable, mammographically evident lesions should be localized presurgically with a guide wire 3
• Localization methods include needle-hook wire, dye injection, or a combination of both 3
• Precise localization may require positioning of more than one wire 3
• Labeled craniocaudal and lateral films showing the hook wire should be sent to the operating room 3
• The incision should be placed closest to the tip of the wire for best cosmetic result 3
• The specimen should be removed in one piece to allow proper margin assessment 3

Important Considerations

• Ultrasound-guided biopsy is useful for nonpalpable masses but usually cannot be relied upon for biopsy of microcalcifications 3, 2
• If DCIS is diagnosed by percutaneous core-needle biopsy, physicians should be aware that invasive carcinoma will be found in about 20% of cases at surgical excision 3, 2
• Vacuum-assisted biopsy has shown higher accuracy than traditional core needle biopsy for microcalcifications, with lower rates of underestimation of invasive disease 4
• Stereotactic core biopsy has demonstrated high sensitivity (97.5%) for diagnosis of malignancy in microcalcifications 5

Pitfalls to Avoid

• Relying solely on ultrasound-guided biopsy for microcalcifications, as this approach is generally inadequate 2
• Removing lesions in multiple fragments during surgical biopsy, which precludes proper margin assessment 3
• Failing to perform specimen radiography to confirm retrieval of calcifications 2
• Underestimating the extent of disease, particularly with increasing lesion size 2