https://www.mayoclinic.org/tests-procedures/breast-biopsy/about/pac-20384812

After decades of development, percutaneous breast biopsy has evolved from blind palpation-guided puncture to minimally invasive procedures navigated precisely by multimodal imaging modalities. A core technical framework consisting of fine-needle aspiration, core needle biopsy and vacuum-assisted biopsy has taken shape, laying the cornerstone for precision diagnosis of breast disorders.

Fine-Needle Aspiration Cytology (FNA)

As the oldest and most minimally invasive biopsy modality, FNA employs ultra-fine 21G–23G needles (0.6–0.8 mm in diameter). Under ultrasound or palpation guidance, the needle is advanced into target lesions, and cellular specimens are harvested via negative-pressure suction. Its prominent strengths include straightforward operation, minimal tissue injury, negligible scarring, low complication rates and cost efficiency.Nevertheless, FNA carries inherent limitations: only isolated cells rather than intact histologic architecture are retrieved, precluding differentiation between in situ and invasive carcinoma. Its diagnostic accuracy heavily relies on cytopathologists' interpretative proficiency with a relatively high false-negative rate. Currently, FNA is primarily indicated for cyst aspiration and decompression, preliminary assessment of palpable superficial masses and cytological examination of suspicious lymph nodes.

Core Needle Biopsy (CNB)

CNB has evolved into one of the gold-standard modalities for solid breast lesion diagnosis. Equipped with larger-bore needles (14G–18G in routine use), the device either relies on spring-powered firing or manual advancement to cut and procure one or multiple intact tissue cores. Compared with FNA, CNB preserves native tissue histology to enable comprehensive pathological workup covering tumor typing, histologic grading and hormone receptor profiling, attaining a diagnostic accuracy exceeding 95%.Performed under ultrasound, stereotactic mammography or MRI guidance, CNB applies to nearly all palpable and nonpalpable breast lesions. Despite marginally higher invasiveness alongside potential complications such as hematoma and procedural soreness, wounds seldom require suturing with rapid postoperative recovery.

Vacuum-Assisted Biopsy (VAB)

VAB marks a landmark breakthrough in minimally invasive breast biopsy by integrating a vacuum negative-pressure system on the basis of core needle biopsy. Under image navigation, the probe is positioned adjacent to the target lesion; vacuum pulls surrounding tissue into the sampling notch, and an embedded rotary cutting blade severs harvested tissue which is subsequently extracted out of the body via suction tubing.Its defining merit lies in continuous acquisition of multiple large-sized specimens (ranging from several milligrams to hundreds of milligrams) from a single skin entry site and one-time positioning, substantially boosting sampling adequacy and precision for tiny lesions and clustered microcalcifications. For small benign neoplasms such as fibroadenoma, VAB can even achieve complete excisional therapy. Accordingly, it is the preferred option for mammography-detected grouped microcalcifications, MRI-enhanced suspicious lesions and cases requiring ample tissue for molecular subtyping. Correspondingly, VAB entails notably higher capital equipment and per-procedure expenditure versus CNB.

Integrated Image-Guided Modalities as a Prerequisite for Precision Biopsy

Real-time image navigation underpins nearly all contemporary percutaneous breast biopsy procedures.Ultrasound guidance stands as the most prevalent and versatile option featuring dynamic real-time visualization, zero ionizing radiation and multiplanar scanning, optimal for palpable or sonographically discernible masses. Stereotactic mammographic guidance serves as the diagnostic gold standard for mammography-only microcalcifications invisible on ultrasound, whereby a computer calculates three-dimensional lesion coordinates for pinpoint cannulation. MRI-directed biopsy targets lesions identifiable exclusively on contrast-enhanced MRI; despite complicated instrumentation and elevated costs, it is irreplaceable for high-risk population screening and pre-breast-conserving-surgery evaluation. In recent years, emerging modalities including tomosynthesis-guided biopsy and contrast-enhanced spectral mammography (CESM)-guided biopsy have entered clinical practice to further improve localization performance for anatomically complex lesions.

Clinical Decision-Making for Modality Selection Based on Multifactorial Assessment

Clinicians customize biopsy approaches after comprehensive evaluation of multiple parameters: imaging features of lesions (dimension, morphology, sonographic visibility), suspicious malignancy risk stratified by BI-RADS classification, patient preference and available medical resources.For instance, ultrasound-guided CNB is first-line for palpable solid masses; simple cystic lesions are managed with FNA aspiration alone; grouped extensive microcalcifications necessitate mammography-guided VAB to guarantee full retrieval of calcified foci. All technical iterations consistently center on core objectives: elevating diagnostic precision, mitigating procedural trauma, optimizing patient comfort and streamlining clinical workflow.