https://pmc.ncbi.nlm.nih.gov/articles/PMC4115763/

Breast biopsy is not a one-size-fits-all procedure. Different clinical scenarios have completely different requirements for biopsy techniques. This article explores the optimal timing for vacuum-assisted biopsy (VABB) and traditional core needle biopsy (CNB) from three dimensions: lesion type, patient's constitution, and subsequent treatment plan.

I. Select Based on the Imaging Characteristics of the Lesion

• Solid masses that are visible on ultrasound (≥ 1 cm): CNB can meet the diagnostic requirements. The typical procedure is to perform 2-4 punctures under local anesthesia using a 14G or 16G needle to obtain sufficient tissue for pathological grading. If the mass is hard in texture (such as invasive ductal carcinoma), the spring force of CNB is sufficient to penetrate.
• Microcalcification clusters (BI-RADS 4C/5): Strongly recommend VABB. Because the calcification foci are usually small and scattered, random sampling by CNB is prone to missing them. VABB can remove the entire calcification area under stereotactic guidance for examination, with a diagnostic accuracy rate of > 98%.
• Non-mass enhancement foci detected by MRI: Since real-time visualization of the needle tip is not possible under MRI guidance, the risk of "blind puncture" by CNB is high. VABB's vacuum suction can fix the tissue, and the laser mark on the needle body is clearly visible under MRI-compatible coils, making it the only approved MRI-guided biopsy method.

II. Adjust According to the Patient's Specific Condition

• If the breasts are small or the lesion is close to the chest wall/skin: The flexible needle of CNB has a longer stroke, which may cause pneumothorax or skin depression when it penetrates beyond the target point. The cutting cannula of VABB is shorter, and the vacuum negative pressure can pull the tissue inward, reducing the risk of penetration. The VABB needle manufactured by Manners is made of 316L stainless steel, with a hardness of HRC 30–40, and combines rigidity and toughness, making it suitable for such delicate operations.
• If there is a coagulation disorder or the patient is taking anticoagulant drugs: VABB can immediately compress tiny blood vessels due to its "suction and cutting" mechanism, resulting in a significantly lower postoperative hematoma incidence (about 1.5%) than CNB (about 4%). Multiple guidelines recommend using VABB for patients with INR > 1.5 first.
• Multiple or multi-centered lesions: VABB can change direction and take samples multiple times during a single puncture, while CNB requires repositioning each time. For bilateral or ipsilateral multi-quadrant lesions, the total operation time and radiation exposure of VABB are lower.

III. According to the Requirements of Subsequent Treatment Decisions

• Before neoadjuvant chemotherapy, it is necessary to determine the molecular subtype: VABB can provide sufficient tissue for ER/PR, Ki-67, HER2 immunohistochemistry, and FISH testing. Sometimes, CNB samples may be distorted due to compression, affecting the interpretation.
• Preoperative marking for planned breast-conserving surgery: VABB can place metal clips (clips) during biopsy to provide a landmark for subsequent surgery. Some VABB systems also have radiofrequency ablation function, which can immediately destroy the remaining lesion after sampling, achieving "diagnosis + treatment" integration.
• Complete resection of benign lesions: For breast fibroadenoma or papilloma, VABB can be used as a minimally invasive rotary cutting method to completely remove the lesion, avoiding open surgery. However, CNB can only take samples and cannot cure the disease.

Conclusion

Clinical decision-making should follow the principle of "disease lesion characteristics as the main guide, patient factors as the adjustment basis, and treatment needs as the orientation." CNB is applicable to the vast majority of routine diagnoses, while VABB plays a unique role in complex, high-risk, and precise-demand scenarios. The complementary use of the two constitutes the complete arsenal for modern breast biopsy.