North American imaging experts endorse new international breast biopsy guidelines

International experts recently developed new guidelines for image-guided biopsies of suspicious breast lesions—offering providers clarity on challenging clinical scenarios.

Published in Insights Into Imaging, the recommendations are intended to “to address the scarcity of evidence-based literature on optimal biopsy approaches in breast radiology." Though not involved in the voting process, a group of breast radiologists from the United States and Canada were invited to review the recommendations and provide additional commentary. The panel recently endorsed the new guidelines, with specific considerations. 

Here are a few of the highlights: 

• The panel agrees that, for lesions visible on sonography, ultrasound-guided core needle biopsy (CNB) is the preferred method over fine needle aspiration (FNA). 
• FNA should be reserved for aspiration of simple and complicated cysts, fluid collections such as abscesses, post-operative seromas, or peri-implant fluid and lesions that are not conducive to CNB due to their location. FNA also is appropriate for centers where “cytopathology is of exceptional quality and there is commitment to on-site cytopathology support to allow for immediate conversion to CNB when atypia is present.” However, this is not the case for most centers. 
• CNB should be considered for cases of recurring mastitis or abscesses that are not responsive to antibiotics to rule out inflammatory breast cancers or other inflammation-based issues. 
• Vacuum-assisted biopsy (VAB) is the preferred technique for masses that are not well visualized on ultrasound and do not have another correlate on other imaging exams. VAB also is appropriate in cases of complex cystic and solid lesions with small (less than 5 mm) solid parts where there is concern that CNB might not allow for adequate sampling of the solid portion of the lesion. 
• For axillary lymph nodes, the use of CNB or FNA should be made based on provider preference. This recommendation was made because the panel was split evenly on preference for each technique. 
• For lesions that are only visible on mammography, DBT or MRI, the group recommends VAB. (They provide more specific guidelines based on imaging findings in the paper linked below.) 

The article also provides additional guidance for high-risk lesions, repeat biopsies and surgical excisions, use of clip markers and radiological-pathological discordance after CNB or VAB. 

The detailed guidelines can be found here.