Stereotactic Needle Biopsy of Breast – some questions
Recently had a request from hospital commander to address a complaint from a patient. Per this woman’s report, she had a concerning 1 cm breast mass on mammogram and was offered a needle localized breast biopsy by one of my partners. Patient was apprehensive about having an excisional biopsy and elected to seek a second opinion at a civilian facility in the area (about 100 miles away) at a tertiary medical center. There she underwent a Stereotactic Core Needle Biopsy (SCNB) with a benign result. She requested to the commander that our small military facility invest in a stereotactic unit for purposes of breast biopsy. At my hospital, between three general surgeons, we perform on average 0 – 2 breast biopsies per week, of which maybe 25 % are needle localized by mammography.
My questions are:
- 1.) Anybody have significant experience with SCNB, as well as Stereotactic Fine Needle Aspiration (in light of discussion last week regarding false positive SFNA)?
- 2.) Is this now considered the “gold standard” or “standard of care” in any community?
- 3.) Anyone offering this as an option to excisional biopsy?
- 4.) What is the cost of the procedure? This patient claims it only cost $120 for her to have the procedure. (I think that was her out of pocket costs after insurance picked up the remainder — whatever that amount was). Several articles have suggested that doing SCNB/SFNA (with a reliable pathologist) saves money because less persons (i.e. physicians) are involved in making the diagnosis. Reportedly, the primary care manager and the radiologist are all that need to be involved in benign breast lesions?
With the ABBI unit by Lorad and Auto-Suture, a SURGEON can do not just a coring out in multiple pieces of an area of microcalcifications, but can actually remove with measurable and verifiable margins, and area of the 20-25 mm’s. The prior Lorad units only carve out, piece at a time, the susperxcted abnormalities…no margins. Studies pending, big marketing…several units in operation in Arkansas…call and talk to the surgeons in Little Rock about it.
I think both SCNB and SFNA are growing increasingly in acceptance around the country. The “gold standard” will always be total excisional biopsy but there is abundant literature showing that in experienced hands the false negative rate with these percutanous techniques is !% or less. I personally prefer core biopsy rather than FNA for the breast because I believe it is more likely to differentiate intraductal from invasive Ca. In a hospital such as yours, with a relatively low surgical volume it makes no sense to invest in expensive equipment. You might have the option of using sonographically directed core needle biopsy if your radioilogist feels comfortable with this technique. It requires no special equipment. Obviously it is only useful for solid lesions and usually not suitable from microcalcifications.
Because most breast biopsies are benign I offer this as an option to vitually all patients with abnormalities on mammogram except those which are obviously malignant. I find it avoids a lot of unnecessary surgery. So far I don’t think we have missed any cancers, but I am careful to bring the patient back for repeat study in 6 months to make certain the lesion has not progressed.
I don’t know the cost of the procedure but it is a whole lot more than $120. I suspect 10X would be more likely. Nevertheless it is cheaper than ambulatory breast localization biopsy and avoids scars, pain, etc.
Even though I am not performing a procedure on these patients I do not think that the surgeon should be out of the loop. I don’t know many radiologists or primary care docs who come close to knowing enough about breast cancer to manage a complicated algorithm such as this.
If you have trouble with this concept, you havent seen anything yet. There are two devices on the market (ABBE and Mammotome which can do total excisional biopsies of mammographic abnormalities percutaneously.
1. We use SCNB and have done over 1000. Our radioogists do them but I am intimately associated with this , its indications, the pathology and when to go the extra step to excisional biopsy.
2. In our community it is the standard of care but everyone should have their indications well worked out. We used to not be able to do very small lesions because of the possibility of removing it entirely and not being able to find it should we need to. Now we can because of the ability to place a titanium clip in its place. Lesions tha are too close to the chest wall or superficial may not be technically possible. Some more diffuse calcifications may require larger biopsy to assure ourselves of adequate sampling. Before a biopsy is done in this fashion, one should be aware of the posssible need to rebiopsy the area and the patient should also.
3.I am comfortable offering this to patients to prove a suspicious abnonmality is cancer before the definitive surgery and to prove a benign appearing solid nodule is benign. We also have a set of criteria recommending an excisional biopsy should a biopsy come back atypical or nondiagnostic.(i.e. normal breast tissue).
4.I believe this procedure runs anywhere from 1100 to 1500 dollars.
We now have a new device that is called a mamotome which can cut and suck out larger pieces of tissue .
There is certainly good data on SCNB but the machine is rather expensive. We have this available about 45miles away. We have not been able to justify the cost for our rural area practice. I discuss this option with any patient reluctant to have a wire-guided biopsy. Have not had any patients bother to travel for the SCNB (that I know about). I understand in the big cities the machines are very busy but I’ve not heard it referred as the “standard of care”. Certainly it is NOT in the rural areas.
FNA- I subscribe the thought that it is a confirmatory test to the clinical and mammographic impression. I have to arrange far in advance to have a pathologist present in the hospital for a frozen section. If a lesion is highly suspicious and FNA+ then definitive surgery is carried out. If the + FNA is a surprise then I do arrange for frozen section confirmation at the time of definitive surgery.
> 1.)
SCNB is highly reliable. In my primary hospital we have done about 1000 since getting our device, a first generation Fischer. A small cadre of radiologists is doing it, but I have surgical friends who are doing SCNB themselves. Core biopsy or the newer Mammotome device which also provides a core-like sample is preferable to to FNA since
1) it gives you a little morphology though the dilemma in DCIS is always knowing how big it really is, which can be not evident mammographically
2) the reliability of FNA is completely dependent on the competence of your cytopathologist and good ones are hard to come by. It is far easier to read core biopsies processed by routine H and E, though atypia on SCBB should always be excisionally biopsied because when pathologists dont see quite enough funky cells to call it DCIS they read it as atypia.
> 2.)
I feel it is simply another option for obtaining a pathologic lesion in non palpable lesions. As elsewhere mentioned US directed core biopsy is another option with far less capital demands: ie 20-30 grand for a good US, versus 150 for a plain Lorad or Fischer table versus 300 for a Lorad with an ABBI device.
> 3.)
Sure. If it is benign excision contributes nothing to the pts health. However, one has to watch out for stuff which could be diffuse and heterogenous. Isolated microcalicifications without a mass and architectural distortions should generally be avoided .
> 4.)
About $600 bucks around here. My radiologist colleagues have discovered that obtaining bits of breast tissue is far easier than managing or even just talking to these pts. They see them back the next day to check the site for bleeding but only give out good news; bad news is referred back to the ordering physician. Serial mammographic observation is a perfectly good option, in my view, for 3 (of 5) lesions, ie , those graded as indeterminate, prob benign.