Biopsy, Breast

Biopsy, Breast

Synonym/acronym: N/A.

Common use

To assist in establishing a diagnosis of breast disease; in the presence of breast cancer, this test is also used to assist in evaluating prognosis and management of response to therapy.

Specimen

Breast tissue or cells.

Normal findings

(Method: Macroscopic and microscopic examination of tissue for biopsy; cytochemical or immunohistochemical for estrogen and progesterone receptors, Ki67, PCNA, P53; flow cytometry for DNA ploidy and S-phase fraction; immunohistochemical or FISH for Her-2/neu) Fluorescence in situ hybridization (FISH) is a cytogenic technique that uses fluorescent-labeled DNA probes to detect specific chromosome abnormalities. Favorable findings:
  • Biopsy: no abnormal cells or tissue
  • DNA ploidy: majority diploid cell population
  • SPF: low fraction of replicating cells in total cell population
  • Her-2/neu, Ki67, PCNA, and P53: negative to low percentage of stained cells
  • Estrogen and progesterone receptors: high percentage of stained cells

Description

Breast cancer is the most common newly diagnosed cancer in American women. It is the second leading cause of cancer-related death. Biopsy is the excision of a sample of tissue that can be analyzed microscopically to determine cell morphology and the presence of tissue abnormalities. Fine-needle and open biopsies of the breast have become more commonly ordered in recent years as increasing emphasis on early detection of breast cancer has become stronger. Breast biopsies are used to assist in the identification and prognosis of breast cancer. A number of tests can be performed on breast tissue to assist in identification and management of breast cancer. Estrogen and progesterone receptor assays (ER and PR) are used to identify patients with a type of breast cancer that may be more responsive than other types of tumors to estrogen-deprivation (antiestrogen) therapy or removal of the ovaries. Patients with these types of tumors generally have a better prognosis. DNA ploidy testing by flow cytometry may also be performed on suspicious tissue. Cancer is the unchecked proliferation of tumor cells that contain abnormal amounts of DNA. The higher the grade of tumor cells, the more likely abnormal DNA will be detected. The ploidy (number of chromosome sets in the nucleus) is an indication of the speed of cell replication and tumor growth. Cells synthesize DNA in the S phase of mitosis. S-phase fraction (SPF) is an indicator of the number of cells undergoing replication. Normal tissue has a higher percentage of resting diploid cells, or cells containing two chromosomes. Aneuploid cells contain multiple chromosomes. Genes on the chromosomes are coded to produce specific proteins. Ki67 and proliferating cell nuclear antigen (PCNA) are examples of proteins that can be measured to indicate the degree of cell proliferation in biopsied tissue. Overexpression of a protein called human epidermal growth factor receptor 2 (HER-2/neu oncoprotein) is helpful in establishing histological evidence of metastatic breast cancer. Metastatic breast cancer patients with high levels of HER-2/neu oncoprotein have a poor prognosis. They have rapid tumor progression, increased rate of recurrence, poor response to standard therapies, and a lower survival rate. Herceptin (trastuzumab) is indicated for treatment of HER-2/neu overexpression. P53 is a suppressor protein that normally prevents cells with abnormal DNA from multiplying. Mutations in the P53 gene cause the loss of P53 functionality; the checkpoint is lost, and cancerous cells are allowed to proliferate.

This procedure is contraindicated for

  • high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site)

Indications

  • Evidence of breast lesion by palpation, mammography, or ultrasound
  • Identify patients with breast or other types of cancer that may respond to hormone or antihormone therapy
  • Monitor responsiveness to hormone or antihormone therapy
  • Observable breast changes such as “peau d’orange” skin, scaly skin of the areola, drainage from the nipple, or ulceration of the skin

Potential diagnosis

Positive findings in:

  • Carcinoma of the breast
  • Hormonal therapy (ER and PR)
  • Receptor-positive tumors (ER and PR)

Critical findings

  • Assessment of clear margins after tissue excision
  • Classification or grading of tumor
  • Identification of malignancy
  • It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Antiestrogen preparations (e.g., tamoxifen) ingested 2 mo before tissue sampling will affect test results (ER and PR).
  • Pretesting preservation of the tissue is method and test dependent. The testing laboratory should be consulted for proper instructions prior to the biopsy procedure.
  • Failure to transport specimen to the laboratory immediately can result in degradation of tissue. Prompt and proper specimen processing, storage, and analysis are important to achieve accurate results.
  • Massive tumor necrosis or tumors with low cellular composition falsely decrease results.
  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in evaluating breast health.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
  • Obtain a history of the patient’s reproductive system, especially any bleeding disorders and other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Note any recent procedures that can interfere with test results. Ensure that the patient has not received antiestrogen therapy within 2 mo of the test.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
  • Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct that prophylactic antibiotics may be administered prior to the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered to promote relaxation and reduce discomfort prior to the percutaneous biopsy; a general anesthesia will be administered prior to the open biopsy. Explain to the patient that no pain will be experienced during the test when general anesthesia is used but that any discomfort with a needle biopsy will be minimized with local anesthetics and systemic analgesics. Inform the patient that the biopsy is performed under sterile conditions by an HCP specializing in this procedure. The surgical procedure usually takes about 20 to 30 min to complete, and sutures may be necessary to close the site. A needle biopsy usually takes about 15 min to complete.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids, anesthetics, analgesics, or IV sedation.
  • Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:
  • Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners) or seeding of the biopsy tract with tumor cells.

  • Ensure that the patient has complied with dietary restrictions. Ensure that the patient has not received antiestrogen therapy within 2 mo of the test.
  • Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld. Ensure that patients on beta-blocker therapy have continued their medication regimen as ordered.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Have the patient void before the procedure.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location, especially right or left breast.
  • Assist the patient to the desired position depending on the test site to be used, and direct the patient to breathe normally during the beginning of the general anesthetic. Instruct the patient to cooperate fully and to follow directions. For the patient undergoing local anesthesia, direct him or her to breathe normally and to avoid unnecessary movement during the procedure.
  • Open Biopsy

  • Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, use antibiotics that are consistent with current guidelines specific to the procedure, and use clippers to remove hair from the surgical site if appropriate.
  • After administration of general anesthesia and surgical preparation are completed, an incision is made, suspicious area(s) are located, and tissue samples are collected.
  • Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
  • Needle Biopsy

  • Direct the patient to take slow deep breaths when the local anesthetic is injected. Protect the site with sterile drapes. Instruct the patient to take a deep breath, exhale forcefully, and hold the breath while the biopsy needle is inserted and rotated to obtain a core of breast tissue. Once the needle is removed, the patient may breathe. Pressure is applied to the site for 3 to 5 min, then a sterile pressure dressing is applied.
  • General

  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
  • Place tissue samples in formalin solution. Label the specimen, indicating site location, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume preoperative diet, as directed by the HCP. Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure. Protocols may vary among facilities.
  • Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
  • Instruct the patient in the care and assessment of the site.
  • Instruct the patient to report any redness, edema, bleeding, or pain at the biopsy site. Instruct the patient to immediately report chills or fever.
  • Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
  • Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services. Provide contact information, if desired, for the American Cancer Society (www.cancer.org).
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient of a follow-up appointment for removal of sutures, if indicated. Decisions regarding the need for and frequency of breast self-examination, mammography, magnetic resonance imaging (MRI) breast, or other cancer screening procedures should be made after consultation between the patient and HCP. The American Cancer Society (ACS) recommends breast examinations be performed every 3 years for women between the ages of 20 and 39 years and annually for women over 40 years of age; annual mammograms should be performed on women 40 years and older as long as they are in good health. The ACS also recommends annual MRI testing for women at high risk of developing breast cancer. Genetic testing for inherited mutations (BRCA1 and BRCA2) associated with increased risk of developing breast cancer may be ordered for women at risk. The test is performed on a blood specimen. The most current guidelines for breast cancer screening of the general population as well as of individuals with increased risk are available from the American Cancer Society (www.cancer.org), the American College of Obstetricians and Gynecologists (ACOG) (www.acog.org), and the American College of Radiology (www.acr.org). Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage the patient to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include cancer antigens, ductography, mammogram, MRI breast, stereotactic biopsy breast, and US breast.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.
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