Diagnostic Biopsy for DCIS

• Stereotactic core-needle or vacuum-assisted biopsy:
  • Is the preferred method for diagnosing DCIS
• Calcifications that appear faint on mammogram or that are deep in the breast and close to the chest wall:
  • May be difficult to target with stereotactic biopsy
• In addition, use of stereotactic biopsy in patients above the weight limit of the stereotactic system (about 150 kg) and in patients with very small breasts:
  • May be impossible
• Patients who cannot remain prone or who cannot cooperate for the duration of the procedure:
  • Are also not good candidates for stereotactic biopsy
• Bleeding disorders and the concomitant use of anticoagulants:
  • Are relative contraindications
• Biopsy specimens:
  • Should be radiographed to document the sampling of suspicious microcalcifications
• Care should be taken to mark the biopsy site with a metallic clip:
  • In the event that all microcalcifications are removed with the biopsy procedure
• In the final biopsy procedure report:
  • It is important to report the:
    • Needle gauge used
    • How many cores were obtained
    • An estimate as to what percentage of the calcifications was removed
• Because stereotactic core-needle and vacuum-assisted biopsy specimens represent only a sample of an abnormality observed on mammography:
  • The results are subject to sampling error
• Invasive carcinoma:
  • Is found on excisional biopsy in 20% of patients:
    • In whom DCIS was diagnosed by a stereotactic core-needle biopsy
• Thus, if the core-needle biopsy results are discordant with the findings of imaging studies:
  • A wire- or seed-localized excisional biopsy can be performed to establish the diagnosis
• After diagnosis using stereotactic core-needle biopsy:
  • Approximately 20% to 30% of patients with ADH, up to 20% of patients with radial scar, approximately 5% to 10% of patients with flat epithelial atypia (FEA):
    • Are found to have a coexistent carcinoma near the site of the biopsy:
      • When complete excision is performed
  • Therefore, when the final pathologic studies from core-needle biopsy procedures indicate either of these diagnoses (ADH, radial scar, FEA):
    • Consideration should be made for excisional biopsy:
      • Though in the case of pure FEA:
        • There is some evidence to suggest that surgical excision is not necessary if all calcifications are removed at the time of biopsy (Calhoun et al., 2015)
• Patients who are not candidates for stereotactic biopsy or who have stereotactic biopsy results that are inconclusive or discordant with the mammographic findings:
  • Should undergo excisional biopsy:
    • This technique is performed with the assistance of preoperative wire or seed localization of the mammographic abnormality in conjunction with the previously placed metallic clip marking the biopsy site
    • Postexcision specimen radiograph:
      • Is essential to confirm the removal of microcalcifications or targeted lesion
    • The excisional biopsy should be performed with the aim of obtaining a margin-negative resection:
      • That can serve as the definitive surgery

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