What Not to Biopsy

  • Bruno D. Fornage


A major source of errors and pitfalls in ultrasound (US)-guided percutaneous biopsies of the breast and regional nodal basins is biopsying lesions that should not be biopsied under US guidance. If a good question is “what should we biopsy,” a better one is “what should we not biopsy.” Needle biopsies have been developed and promoted to avoid unnecessary surgical biopsies. As a result, the number of surgical biopsies has decreased, but this decrease has been accompanied by a proliferation of unnecessary “benign” and nondiagnostic needle biopsies. As US scanners show smaller and smaller lesions (with benign ones outnumbering the malignant ones by a factor of thousands) and the line between minute fibrocystic changes and normal anatomy is blurred, the proliferation of unnecessary biopsies is becoming a growing problem. This chapter focuses on when not to proceed with US-guided percutaneous biopsy.


Unnecessary biopsies Pseudolesions Artifacts Learning curve Breast imager’s anxiety Technologist’s anxiety Patient’s anxiety Reliable ultrasound diagnosis of benign lesions Cost Training Mentoring Coaching Follow-up with imaging 

Supplementary material

Video 17.1

Area of distortion in the upper inner quadrant of the right breast seen on mammograms in a 45-year-old woman with no history of cancer. US scanning back and forth over the area of distortion seen on mammograms shows the pulling of the tissues toward the center of the lesion (arrow) but no unequivocal mass in its center that would serve as a reliable target for US-guided CNB. A stereotactically guided VAB was performed instead (see also Fig. 17.1) (MP4 7259 kb)

Video 17.2

FNA of a pseudomass in a patient with fibrocystic changes. Dynamic US examination shows that the area of decreased echogenicity (arrow) that was biopsied is a pseudomass. Several other similar areas of decreased echogenic tissue scattered throughout the breast represent diffuse minor fibrocystic changes and do not warrant a biopsy (see also Fig. 17.4) (MP4 10993 kb)

Video 17.3

Extensive sampling during US-guided FNA of the focally distended duct shown in Fig. 17.11, which yielded a thick inspissated acellular material. (MP4 10687 kb)

Video 17.4

Fat lobule mimicking a fibroadenoma. Dynamic maneuvers (lateral motion) during US show the softness and deformability of the hypoechoic pseudomass, confirm a fat lobule, and exclude the presence of a neoplasm (see also Fig. 17.12) (MOV 4206 kb)

Video 17.5

A suspicious mass created by a small amount of fat in the shadow cast by a Cooper’s ligament (see also Fig. 17.13). Dynamic maneuvers (direct compression followed by lateral displacement) during US show the deformability and compressibility of the pseudolesion, thereby confirming its fatty nature and avoiding an unnecessary biopsy (MOV 9597 kb)

Video 17.6

A focally distended duct mimicking an intraductal papillary lesion. Compression with the US probe shows that the pseudomass is in fact mildly echogenic intraductal fluid, which moves freely within the prominent duct (see also Fig. 17.14) (MOV 5080 kb)

Video 17.7

A typical sebaceous cyst in the left parasternal region in a 71-year-old woman with a history of bilateral breast cancer. Dynamic maneuvers (vertical compression) during US show that the sebaceous cyst remains in intimate contact with the deep dermis and unaltered, while the surrounding subcutaneous fat is compressed around it (see also Fig. 17.15). Note the compressible subcutaneous veins (MOV 5935 kb)


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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Bruno D. Fornage
    • 1
  1. 1.The University of Texas MD Anderson Cancer CenterHoustonUSA

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