Breast biopsies are among the most common type of biopsy performed. The cells and tissue obtained by breast biopsy establish the presence of breast disease, diagnose histopathology, and classify the process. They also confirm and characterize calcifications noted in prebiopsy mammograms. The breast tissue is examined to determine surgical margins, presence or absence of vesicular invasion, tumor type, staging, and grading. Secondary studies relevant to survival may include imaging procedures, along with the following prognostic markers. (Also see Tumor Markers in Chapter 8 for more information.)

1. ER and PR. These hormone receptors are indicators of prognosis and are used to manage hormonal therapy in breast and endometrial cancer. Immunohistochemical staining aids recognition of metastatic breast cancer.

2. DNA ploidy. This test measures cell turnover or replication; it is used to predict prognosis and shorter survival times by the presence of aneuploid (rapidly replicating cells) for certain tumor types, such as breast, prostate, and colon; it is less clear for ovarian, lung, kidney, and bladder (urine) tumors (66% of breast cancers are aneuploid).

3. SPF. This test is done to predict survival and reduced chance of relapse. Low levels of SPF appear to have longer survival and reduced chance of relapse. SPF is the DNA synthesis phase obtained by a statistical method.

4. Cathepsin D. This test is done to determine prognosis. The presence of this lysosomal protease is estrogen related and may promote tumor spread. Prognostic significance remains ambiguous.

5. EGF reception. This test is done to predict survival time. Presence is correlated with ER negativity, aneuploidy, increased S-phase factors, and lymph node metastases. Increased EGF reception may be associated with worse relapse-free and survival time.

6. p53 gene. This test is used to predict prognosis. This tumor suppressor gene regulates cell cycles. Some healthcare providers believe that the prognostic value of the p53 gene is second only to lymph node status.

7. c-erbB2 (HER2) oncogene. This test determines which patients are most likely to benefit from high doses of chemotherapy. High levels of this oncogene receptor are associated with poor response to conventional chemotherapy and may be a marker for patients likely to benefit from high doses of chemotherapy. HER2/neu levels may also be determined in a blood specimen.

Gene profiling technologies have also allowed identification of different types of breast cancer, such as luminal A and luminal B (hormone receptor–positive tumors that arise from luminal cells), HER2 (hormone receptor–negative tumors), BRCA (tumors due to gene mutations), and basal (negative for PR and ER).

1. See Chapter 10 for image-guided tumor localization study before biopsy.

2. Breast tissue specimens may be obtained by open surgical technique, x-ray–guided core biopsy, needle biopsy, or magnetic resonance imaging (MRI)-guided biopsy.

3. MRI-guided breast biopsy is performed by positioning the patient with both breasts in a dedicated surface breast coil. The breast to be biopsied is positioned in a compression device, and a marker is taped over the suspected area of the lesion. Subsequently, an IV injection of gadopentetate dimeglumine is given, and images are acquired after contrast injection. This process is used to determine the depth and location of the lesion for insertion of a probe. A needle can now be introduced and a small, cylindrical tissue sample obtained. The procedure generally takes less than 60 minutes.

4. Label specimen with the patient’s name, date, and test(s) ordered and place these specimens in a biohazard bag, take directly to the laboratory, and give to the pathologist or histotechnologist. The breast tissue is examined and the extent of the tumor determined. Reaction margins and the grade and stage of disease are identified.

5. See Chapter 1 guidelines for intratest care.

1. After breast tissue is examined, the extent of the tumor is determined. Resection margins are evaluated, and grade and stage of disease are identified. The further dedifferentiated a tumor becomes, the further it deviates from the normal diploid state. This may be expressed as a tetraploid or aneuploid state according to the amount of DNA on the stained tissue (DI of between 1.0 and 2.0). The more the cells in the S or DNA phase, the more aggressive the tumor.

2. Favorable prognostic indicators include tumor size lesser than 1 cm, a low histologic grade, negative axillary lymph nodes, and positive ER and PR.

3. Fibroplasia and fibroadenoplasia are benign conditions.

Pretest Patient Care

1. Explain biopsy purpose and procedure. Obtain and record relevant family or personal history of prior biopsy, trauma, recent or current pregnancy, nipple discharge, location of lump, and how lesion was detected. Obtain or confirm a signed, witnessed consent form.

2. Be aware that open breast biopsies are performed under local or general anesthesia. Sedation may be used with local anesthetic agents. Nothing by mouth is required when general anesthesia is used.

3. Provide information and support, recognizing the fear the patient experiences about the procedure.

4. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Normal

Negative for malignant or other abnormal cells and tissue

Prognostic markers of no significance or negative

No vascular invasion

DNA index (DI): 0.8–1.2 on the diploid scale

Proliferative antigen index of 10% S phase: 7% = amount of cells on the S phase