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FAQ Biopsies                                       Link to Biopsy Medical Articles

After being screened for breast cancer, a suspicious lump has been found.  How is
the lump biopsied?

Primarily, there are three ways to biopsy a suspicious lump:(1) fine needle biopsy
(FNA), (2) large gauge needle (core) biopsy,  and (3) excisional biopsy during
which the whole lump is surgically removed.

I have just had a mammogram and my doctor sees a suspicious mass in my breast.
 My doctor has suggested a needle biopsy.  Is there any downside to this
procedure?

Background: Needle biopsies pierce the suspicious breast mass to draw out tissue for
analysis.  Some researchers fear these procedures may spread (or seed) the cancer,
causing something called "needle track metastasis." Others feel this possibility is not a
significant concern or that the immune system, surgery and/or radiation that follows will
clean up the area. Each individual must review the information that is presented in this
BIOPSY section with her doctor and decide for herself whether or not to undergo these
procedures.

Hot News: In June 2004, the results of the bombshell Hansen study, "Manipulation
of The Primary Breast Tumor and The Incidence of Sentinel Node Metastases From
Invasive Breast Cancer," were published in the American Medical Association's
prestigious journal, Archives of Surgery,  revealing that
patients undergoing  fine
needle biopsies were 50% more likely to have micrometastases spread to the
sentinel lymph node than those patients having the entire tumor removed for biopsy.

The implication of this discovery is that a woman without lymph node involvement,  who
would have been staged at a low level,  
now will be staged higher,
her disease considered more advanced, and more aggressive treatment might be
recommended.

Over the years, several researchers have voiced serious reservations about routine
needle biopsies, but they were mostly ignored by their colleagues. Hansen's
research team cited their predecessors, and  the research path leads back
several decades. It's hard to understand why The Archives of Surgery study, which
embodies all of these reservations about needle biopsies, didn't make the front
page of the New York Times.

Cancer authority, Ralph Moss, comments in his February 6th, 2005
Moss Reports
Newsletter:

"Imagine the outrage these patients will feel when they learn that many of these sentinel
node metastases were caused not by the natural progression of their disease but
directly by the actions of well-intentioned (but ill informed) doctors. Imagine, further,
what will happen when patients find out that questions have been raised about the
safety and advisability of needle biopsies for a number of years by some of the finest
minds in oncology. Imagine the disruption of the smooth functioning of the "cancer
industry" when patients start demanding less invasive ways of diagnosing tumors.  And
imagine the class action lawsuits."  

Significant parts of the Hansen study below are highlighted in red. Patients  may want to
include it in their
Patient Portfolio.

Manipulation of the Primary Breast Tumor and the Incidence of
Sentinel Node Metastases From Invasive Breast Cancer

Nora M. Hansen, MD; Xing Ye, MS; Baiba J. Grube, MD; Armando
E. Giuliano, MD

Arch Surg. 2004;139:634-640. Hypothesis  The incidence of
sentinel node (SN) metastases from invasive breast cancer
might be affected by the technique used to obtain biopsy
specimens from the primary tumor before sentinel lymph node
dissection. Design  Prospective database study. Setting  The
John Wayne Cancer Institute.

Patients and Methods  We identified 663 patients with
biopsy-proven invasive breast cancer who underwent sentinel
lymph node dissection between January 1, 1995, and April 30,
1999. Patients were divided into 3 groups based on type of
biopsy: fine-needle aspiration (FNA), large-gauge needle core,
and excisional. A logistic regression model was used to
correlate tumor size, tumor grade, and type of biopsy with the
incidence of SN metastases.

Results  Of the 676 cancers, 126
were biopsied by FNA, 227 by large-gauge needle core biopsy,
and 323 by excisional biopsy before sentinel lymph node
dissection. Mean patient age was 58 years (range, 28-96 years),
and mean tumor size was 1.85 cm (range, 0.1-9.0 cm). In
multivariate analysis based on known prognostic factors,
the
incidence of SN metastases was higher in patients whose cancer
was diagnosed by FNA (odds ratio, 1.531; 95% confidence
interval, 0.973-2.406; P = .07, Wald test) or large-gauge needle
core biopsy
(odds ratio, 1.484; 95% confidence interval,
1.018-2.164; P = .04, Wald test) than by excision. Tumor size
(P<.001) and grade (P = .06) also were significant prognostic
factors.

Conclusions  Manipulation of an intact tumor by FNA or
large-gauge needle core biopsy is associated with an increase in
the incidence of SN metastases, perhaps due in part to the
mechanical disruption of the tumor by the needle.
The clinical
significance of this phenomenon is unclear.
----------------------------------------------------------------------------------
According to the Hansen study, whether the increased incidence of sentinel node
metastases will promote a regional recurrence or affect overall survival is unknown. Will
a core biopsy increase the chance of a local recurrence? Another research team, led by
A. Chen, published "Local Recurrence of Breast Cancer After Breast Cancer Therapy in
Patients Examined by Means of Stereotactic Core-Needle Biopsy," in the journal
Radiology in 2002 after finding that a core biopsy followd by a lumpectomy and radiation
does not increase the risk of a local recurrence.  It is worth noting that the authors of
this study speculate that there might be an increased risk of a local recurrence unless
adjuvant radiation is used.   (See Thurfjell, et al., Acta Radiologica, [2000 ] and Chen, et
al.,Radiology,[2002] in the MEDICAL ARTICLES BIOPSY section.)


What is the impact of the increased incidence of SN metastases on overall survival?

The American College of Surgeons' Z0010 study will address the significance of
micrometastases in the regional lymph nodes of patients with invasive breast cancer.













Cited below are relevant excerpts from the much respected
Townsend Letter for Doctors
and Patients (
2004). The article elaborates upon the problems with stereotactic  (also
called "core" biopsies because a bigger needle is used to draw out tissue) biopsies.

Stereotactic Breast Biopsy: what you should know but probably weren't told

Townsend Letter for Doctors and Patients, June, 2004 by Whitney S. Hibbard
[excerpted]

Question. Are there any risks inherent in the stereotactic needle biopsy procedure?

Answer. Yes. A survey of histological studies reveals that there is a clear danger of
seeding needle tracks with malignant cells "displaced in breast stroma or in
lymphovascular channels, associated with the traumatic effects of a needling
procedure," according to Dr. Rosen, Department of Pathology, Memorial Sloan-
Kettering Cancer Center. Consequently, Dr. Rosen warns that "with tissue disruption,
lymphatic and vascular channels may also be breached, and it is conceivable that
detached epithelial fragments may enter vascular channels and perhaps even be
transported to lymph nodes." (1)

Question. What is the frequency of malignant needle track seeding?

Answer. The frequency with which this occurs and the degree to which this leads to
metastases is uncertain. Studies range from an insignificant .003% frequency of
malignant needle track seeding to a horrifying 89%. (2) Clearly, more research is
needed to assess accurately the actual incidence. It is extremely important to
understand, however, as Dr. Austin clarifies in Breast Cancer: What You Should Know
(But May Not Be Told) About Prevention, Diagnosis, and Treatment, that it is not breast
cancer per se that kills: "What kills patients is the spread of cancer to distant parts of
the body--distal metastasis."

Question. Isn't this really a moot concern because if a biopsy reveals a malignant
lesion it will be removed anyway?

Answer. Maybe. The question is whether the whole needle track would be removed
during surgery, i.e., surgeons unaware of the malignant needle track seeding problem
may not do the necessary excision. Furthermore, it must also be asked as to how long
it takes for malignant cells leaked into a vascular channel to be distributed to other
areas of the body (e.g., neighboring lymph nodes)? In all likelihood this would be fait
accompli long before a scheduled surgery.

Question. What are a patient's diagnostic procedural options if she chooses not to
undergo fine needle biopsy?

Answer.
Critics of the procedure recommend lumpectomy with subsequent
histological examination once the tumor is safely removed, or surgical excision of
the needle track after biopsy. (3)

Question. Is there a problem of "false negatives" (i.e., even though a malignant tumor
is present, it is missed with the needle so the pathology report is negative) with
stereotactic needle biopsy?

Answer. Allegedly, the X-ray guided needling in the stereotactic procedure will reduce
greatly the number of "false negatives" which run as high as 23% in non-stereotactic
needle biopsy procedures! (4)

Question. Is there a danger inherent in the additional radiation exposure?

Answer. Clearly "yes." According to Dr. Gofman, MD, PhD, in Radiation and Human
Health: A Comprehensive Investigation of the Evidence Relating Low Level Radiation
to Cancer and Other Diseases, ionizing radiation is a known carcinogen, there is no
safe exposure level to ionizing radiation, and the effects of radiation exposure are
cumulative throughout one's life. Specific to breast cancer, Dr. Gofman presents
compelling evidence in his new book, Preventing Breast Cancer: The Story of a Major,
Proven, Preventable Cause of This Disease, that about 75% of those cancers are
caused by exposure to ionizing radiation, principally from medical X-rays. People
should not forget the massive and heavily promoted early detection mammogram
program in the 1950s and 1960s of women under 50 which was scrapped by the
National Cancer Institute because the incidence of cancers caused by repeated
radiation exposure was unacceptable. That program "caused between 55,000 and
65,000 future cancer deaths per year!" according to Dr. Gofman, a radiologist with a
doctorate in medical physics, who headed a $24,500,000 seven-year study on the
effects of radiation on human health.

[end of excerpt]

See full article, Hibbard W, "Stereotactic Breast Biopsy",2004 article in MEDICAL
ARTICLES BIOPSY section.)

----------------------------------------------------------------------------------
Since both FNA and core needle biopsies may be associated with a higher
incidence of sentinel lymph node metastases than that associated with surgical
biopsy, is there any downside to undergoing excisional surgical biopsy, which will
remove the whole tumor?

In the previously cited article published in The Breast (2000), Dr. Robert Rosser
advocates altering the surgical technique to avoid trauma to the breast in order to
prevent any possible creation of injury-induced micrometastases, which he calls  
traumets.

Dr. Rosser writes, "The surgical technique should be altered to avoid grasping a
tumor at any time.  Retraction and control of the tumor would be better
accomplished by placing a large retention suture through the tumor, perhaps
several times through the tumor and using the suture to control the tumor while
cutting around it."


I've decided to take my chances with a needle biopsy. If I am premenopausal, is
there any advantage to timing the biopsy procedure with a particular part of my
menstrual cycle?

For premenopausal women, timing the surgical procedure with the menstrual cycle
has now been studied in the context of needle biopsy as well as in that of breast
surgery. It appears that timing breast piercing or surgery after ovulation is worth   
considering. A relevant study follows:

J Surg Oncol. 2000 Jul;74(3):232-6.
Menses and breast cancer: does timing of mammographically
directed core biopsy affect outcome?
Macleod J, Fraser R, Horeczko N.
Department of Surgery, University of Alberta, Edmonton, Canada.

BACKGROUND AND OBJECTIVES: Studies have shown molecular, genetic and
cellular changes in breast cancer during the menstrual cycle. Changes in
proliferative and metastatic potential of breast cancer cells during menses could
explain improved survival when tumors are surgically removed in the luteal [after
ovulation] phase. This study examined if timing of mammography/core biopsy
(MAM-CB) also affected breast cancer prognosis (histological tumor grade). METHODS:
Eighty-five premenopausal women undergoing MAM-CB at one clinic between March
1995 and February 1998 were retrospectively studied. All patients had Stage I or II
breast cancer surgically treated. Patients were grouped by phase of menses at
MAM-CB:follicular (F, Days 0-14) or luteal (L, Days 15-35). Groups were comparable in
age,menarche, family history, nulliparity, breastfeeding, and total percentage of clinically
palpable tumors. Pathological characteristics of the tumors (tumor size, tumor type,
estrogen and progesterone receptor status, axillary lymph node status, the
presence of lymphatic or vascular invasion and extranodal metastasis) was also
comparable across the 2 groups. RESULTS: Low-grade tumors were more frequent
in the MAM-CB group L, whereas high-grade tumors were more common in the
MAM-CB group F (P = 0.002, chi2(4) = 17.06). CONCLUSIONS: Timing of MAM-CB
in relation to menses may be a factor influencing breast cancer outcome. Future
studies examining the effect of menses on the outcome of breast cancer should
consider the potential effect of the timing of MAM-CB.
------------------------------------------------------------------------

I do not want anyone cutting into my breast. Are there alternatives to surgery?

No Amazon member has definitively gotten rid of a tumor without surgery. One
member has shrunken hers with hormone modulation, and another used an
alternative medicine program to help shrink hers, but neither person shrank her
tumor to the point of disappearance. Conventional medicine might suggest using"neo-
adjuvant" chemotherapy to shrink the mass, but this methodology  is customarily used
in conjunction with a later surgery--which is why it's also called pre-operative
chemotherapy.

What about these cancer salves I read about? Do they remove the tumor
without surgery?

Cancer salves may work, but no one associated with the Amazon Group has
experienced any lasting benefit associated with using them to treat breast tumors.

My biopsy came back positive for cancer.  I want a second and maybe a third
opinion. How long do I have to make a decision about what kind of surgical
procedure to have?

Any reputable doctor will tell you there is time to schedule second and third opinions
after a breast cancer diagnosis, but bear in mind that studies and articles show that
expeditious surgery may counteract potentially negative effects of cells displaced by
past needle biopsies.

This website is intended as information only. The editors of this site are not medically-trained.
Please consult your licensed health care practitioner before implementing any health strategy.
The information provided on this site is designed to support, not replace, the relationship that
exists between a patient/site visitor and his/her existing physician. This site accepts no
advertising. The contents of this site are copyrighted 2006 by Breast Cancer Choices, Inc.
Contact us for reprint permission.
Web page updated January 7, 2008.
The Chen (2002) needle biopsy study and other studies suggest needle
biopsies may not only raise the risk of spreading cancer cells within the breast
tissue itself to such a degree that radiation therapy is recommended, but
Hansen (2004) suggests that these biopsies may also spread them farther,
beyond the breast, to the sentinel node.

The take home question is:

Do you really want to undergo a diagnostic procedure, such as a needle biopsy,
which may increase your risk of spreading cancer cells when removing the
whole tumor with an excisional biopsy is an option?
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