Minimally Invasive Biopsies for Breast Concerns: Precision, Convenience, and Minimal Scarring

One of the first steps in diagnosing your breast concern involves a biopsy. A safe and convenient way to perform a biopsy is to pass a needle through the skin into the lesion and give the sample to a pathologist for assessment. This type of biopsy is minimally invasive and rarely leaves a scar. It also does not require a stay in the hospital, and the patient can avoid the operating room. It should not affect your daily routine, and there are no restrictions after the procedure. 

These biopsies are often done with the guidance of ultrasound or mammography to target the area precisely. A marker is then placed in the area so we can continue locating it in the future.

The terms we use to describe this are ultrasound-guided or stereotactic breast biopsy. Breast surgeons and radiologists are specialists who perform these biopsies. 

If a lump can be felt through the skin, biopsies are sometimes performed without an ultrasound or mammogram. These biopsies are performed in our office for the convenience of our patients. However, sometimes we need help getting an adequate sample with a needle biopsy. In this case, a surgical biopsy will need to be performed, which can be done at our office with general anesthesia. 

The Different Types of Cancer

Ductal Vs. Lobular

Your pathology report may specify whether you have invasive ductal carcinoma, DCIS, or lobular carcinoma. These are essential distinctions; however, much treatment is based on how cancer cells behave, determined by tumor markers and biology. 

Lobular carcinoma spreads through breast tissue in a way that is difficult to detect on mammography. It can also be difficult to palpate or feel during a breast exam. This is probably the most concerning characteristic of lobular carcinoma because it can be challenging to diagnose. 

Ductal carcinoma in situ (DCIS) is a type of breast cancer still within the duct and does not usually travel to other body systems. Minimal treatment is required, often consisting of a lumpectomy and occasionally oral medication.

Lobular carcinoma in situ (LCIS) does not behave as breast cancer. Much research has been performed on LCIS in recent years, and researchers' and breast specialists' consensus is that no specific treatment is often needed.

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Tumor Markers

Over the past 2-3 decades, an incredible amount of research has been done on breast cancer. One of the most important breakthroughs was discovering that most breast cancer is sensitive to estrogen. This has led to the development of medications that block estrogen. Your breast cancer pathology report will state whether your cancer is estrogen receptor-positive (ER+) or estrogen receptor-negative (ER-). 

Breast cancer can also be sensitive to progesterone. This is also reported as progesterone receptor positive (PR+) or negative (PR-). This also factors into our treatment plan; however, it does not have as much impact as the estrogen receptor status. 

Another critical tumor marker is referred to as HER2/NEU. This is reported as positive/amplified or negative/not amplified; HER2+ or HER2-.

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This growth factor receptor is found in some breast cancer cells. Breast cancers that are HER2+ are treated with a particular chemotherapy regimen. Some of the most challenging breast cancers to treat are HER2+. A lot of current research is focused on this specific type of cancer. 

We use the phrase triple-negative breast cancer (TNBC) to describe a subset of breast cancers that are negative for all three tumor markers. This type of breast cancer tends to be more aggressive, and these women are often given chemotherapy before surgery. Breakthroughs in research have led to some excellent outcomes in recent years in patients with TNBC. 

The phrase triple positive breast cancer refers to cancer that is ER+, PR+, and HER2+. Inflammatory breast cancer (IBC) is, fortunately, very uncommon. Patients with IBC receive intense care from each specialist caring for them. The surgeon, the medical oncologist, and the radiation oncologist will communicate the timing of surgery, chemotherapy, and radiation for all cancers. Our treatment plans are based on several factors, as breast cancer care is individualized based on these tumor markers and risk factors to optimize patient outcomes. 

Cancer Staging

Upon being diagnosed with breast cancer, your first question may be, “Has the cancer spread?” Soon after your diagnosis, we will begin an assessment to evaluate the location of the cancer. 

First, we begin by looking at the breast and the lymph nodes. Specific cancer characteristics can indicate an increased likelihood that the cancer will spread. In this circumstance, we are more likely to order additional testing, such as a PET or CT scan. 

Your breast care team will ask questions about your symptoms, which will help determine if the cancer has spread. Symptoms that may be concerning are: 

  • New onset of headaches
  • Rib pain
  • Bone fractures
  • Worsening cough
  • Unusual back pain
  • Any other symptoms that are new and unusual for the patient 

According to the American Cancer Society, less than 7% of patients have metastatic disease (stage 4), where cancer spreads beyond the breast and lymph nodes under the arm to other organs and systems of the body.

  • Stage 1 breast cancer involves the breast only.
  • Stage 2 & 3 is cancer of the breast and lymph nodes. 
  • Stage 4 is metastatic cancer.

The AJCC American Joint Committee on Cancer and the American Cancer Society have excellent resources on the web to learn more about the stages of breast cancer.

Sometimes a biopsy will return showing DCIS (ductal carcinoma in situ). This type of cancer cannot spread because it is contained within the duct. Therefore an extensive staging assessment is not necessary. 


Women commonly think of their surgery options as having a mastectomy or lumpectomy. A lumpectomy is frequently referred to as breast-conserving surgery. For most women, this is the best treatment option. After a lumpectomy, your breast contour should be relatively similar to before the procedure. A lumpectomy is the best treatment option for most women because recurrence rates are as low as after a mastectomy, mainly if the patient follows through with additional postoperative treatment like radiation and oral or IV therapy. 

Mastectomy, or removal of the entire breast, is better for certain women, such as those with multi-focal or diffuse breast cancer (cancer in several spots within the same breast). Good candidates for mastectomy include:

    • Patients with cancer in multiple sites in the same breast (multi-focal)
    • Women with a higher-than-normal risk of recurrence due to genetics
    • Women who are not a candidate for radiation therapy
    • Sometimes, a mastectomy is performed due to patient preference 

    Several women who have a mastectomy are good candidates for reconstruction. A conversation about a mastectomy is incomplete unless options for reconstruction are discussed. Reconstruction can be done on the same day as the mastectomy or may be delayed until the treatment regimen is complete. In certain situations and for certain patients, we discuss bilateral mastectomy, with or without reconstruction. 

    Evaluation of axillary lymph nodes is an integral part of cancer treatment. Sometimes, a needle biopsy is done on a lymph node before surgery to help with staging and to plan treatment. The most common surgery on the lymph nodes is sentinel lymph node biopsy. This technique allows us to be very specific in identifying the appropriate lymph nodes that may contain cancer. We can locate the lymph nodes by injecting a blue dye around the nipple on the day of surgery or a radioisotope before an x-ray. In surgery, a small incision is made under the arm, and the lymph node is identified and removed. This specimen is then evaluated for the presence of cancer cells. This information will be vital when planning your treatment. 

    Sometimes an axillary lymph node dissection is done, which involves removing the majority of lymph nodes under the arm and is reserved for women who have advanced breast cancer. Generally, this is only done for women with more than three involved nodes before surgery. We reserve this surgery for patients meeting these criteria because of additional risks. Don’t be afraid to ask your breast care team about the risks you are concerned about. 

    Other treatments

    Guideline-based breast cancer care includes a medical oncologist, a radiation oncologist, and a surgeon. If you are diagnosed with breast cancer, you should see these specialists who each have a role in managing your treatment. 

    Many women who have breast cancer benefit from radiation therapy. Radiation therapy is a proven effective and safe treatment.

    Almost every woman with breast cancer will either be prescribed oral medication or receive chemotherapy, or a combination. Chemotherapy is usually delivered through a central venous catheter connected to a port underneath the skin. Inserting the catheter is a simple and safe procedure that can be performed in the office.

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