Image-guided biopsy of clinically occult nipple lesions: techniques and learning points

Percutaneous biopsy is the standard of care for breast lesions, except nipple lesions which are primarily biopsied by excision due to perceived risks of pain and bleeding. However, excisional biopsy of nipple lesion inevitably leads to disfigurement and possible loss of the nipple-areolar complex (NAC), highlighting the need for minimally invasive biopsy techniques. We present our experience of seven patients who underwent ultrasound-guided core biopsy or vacuum-assisted biopsy (VAB) for sampling of clinically occult nipple lesions. All patients tolerated the biopsy procedures well with minimal to mild pain. A patient was complicated by a subcentimetre skin laceration which was sutured with good wound healing and cosmesis. Radiopathological concordance was achieved in all patients. Five out of 7 patients did not require further surgical management after biopsy, avoiding the unnecessary disfigurement from conventional excisional biopsy of nipple. The remaining two patients were diagnosed with pre-malignant lesions and further surgical treatment was performed. This study highlights the important pre-procedural preparation, biopsy techniques and learning points derived from our experience. Learning points that increase the efficacy of obtaining suitable tissue samples, such as enhancing lesion visualisation, appropriate biopsy needle selection and optimising analgesia were discussed. Potential complications and common pitfalls, such as mimics of nipple calcifications, were also included. In conclusion, image-guided percutaneous biopsy techniques are feasible minimally invasive alternatives to excisional biopsy of the nipple.