Frequent Questions

Vacuum assisted biopsy (VAB) is a breast biopsy procedure which uses a special device consisting in a scalpel blade inside a hollow needle connected to a vacuum pump or system. By combining the aspiration produced by the vacuum system with the action of the scalpel blade, the lesion is cut up in multiple small fragments which then are aspirated or removed from the breast.

Vacuum assisted biopsy (VAB) is not a new procedure. It was first used in the mid nineties in microcalcification biopsies. Microcalcifications are a kind of breast lesion. They remain an important indication of VAB, and the biopsy is normally performed with a stereotactic device and the patient in sitting position or lying on her side or stomach.

VAB incorporates two new aspects:

• It can be performed with ultrasound guidance, which is more convenient than the stereotactic procedure, as the patient can lie on her back or slightly leaning to one side.
• New indications: since the beginning of the century, new alternatives to breast surgery have been developed both for diagnosis confirmation following a mammogram, an ultrasound examination, or another kind of incisional breast procedure, and for the removal of certain lesions which are not cancer.

Vacuum assisted biopsy (VAB) has numerous advantages compared to the conventional surgical biopsy:

• First, it requires no hospital admission. VAB is performed as an outpatient procedure and the patient can return home afterwards.
• Second, it is done under local anaesthetics, therefore all the complications associated to general anaesthetics are eliminated and there is no need for other tests (X-rays, ECG, blood tests, etc.) and consultations to the anaesthesiologist prior to the intervention.
• Third, unlike procedures performed in the operating room, it requires no breast cuts or excisions. The biopsy needle is introduced through a small skin incision, and the lesion is “removed” through the needle so that the skin does not have to be cut nor sewn afterwards.
• Fourth, all potential complications are rarer and milder than with open breast surgery techniques.
• And last of all, although not less important, post-procedure recovery is much faster than after a surgical operation, and patients resume their normal activities after a few days.

Breast biopsy techniques have developed considerably over the last decades. Prior to the introduction of puncture needles (fine needle aspiration or fine needle cytology, and core needle biopsy), all suspicious lesions detected in mammograms or ultrasound images were surgically resected in the operating room in order to diagnose them. If the outcome of the tests turned out to be cancer, usually, another intervention was required to complete treatment.

Fortunately, needle puncture procedures have been available for a number of years now, making it possible to confirm a diagnosis before surgery or even to avoid surgery. Nevertheless, these procedures have limitations and in some cases the removed samples or pieces are so small that a surgical biopsy has to be used to confirm the diagnosis.

The benefit of vacuum assisted biopsy (VAB) is that bigger, more numerous samples are removed, and even complete elimination of the lesion is possible. This way, uncertain outcomes are much less common, and surgical biopsies are rarely necessary. Another benefit is that, unlike what happens with the other needle puncture techniques, if a non-cancerous lesion is completely removed, the treatment can be regarded as finalized.

Vacuum assisted biopsy (VAB) is not painful, although pain tolerance is different for each individual. The anaesthetic injection can cause some discomfort, as the volume of anaesthetics required is bigger than in other types of procedures, and usually the lesion has to be circled around. Once the anaesthesia has kicked in, the rest of the procedure should be painless. If necessary, more anaesthetics can be injected during the procedure.

Since vacuum assisted biopsy (VAB) is not an open biopsy procedure, like the ones usually performed in the operating room, a small incision of not more than 2-3 millimetres gives enough space for introducing the needle. Sewing is not necessary either; a few thin sticky paper-like strips are placed over the incision and removed after 3-4 days. As the skin is not cut or sewn, a few weeks after the procedure, the scar will look like a freckle which very often ends up disappearing. The only exceptions are patients prone to unesthetic scars; in these patients, the scars will be more noticeable.

Any person can be a candidate for vacuum assisted biopsy (VAB) regardless of their age (from teenagers to the elderly) or gender, as even though women are more likely to have breast lesions requiring biopsies, men can also need them.

Another advantage of VAB is that it can be performed in patients with conditions that could create difficulties for a surgical approach; heart or pulmonary disorders may occasionally put the patient at risk when under the effects of anaesthesia in the operating room. Patients with these conditions are considered good candidates for VAB because it is performed under local anaesthesia.

Usually, there are three reasons for recommending a breast biopsy:

1. to investigate if a lesion spotted in breast imaging is cancerous
2. after fine needle aspiration or a core needle biopsy, when results are unclear
3. to remove or treat a non cancerous lesion

In these three cases, vacuum assisted biopsy (VAB) may be an appropriate alternative to the surgical biopsy depending on the type of lesion. Each individual case must be assessed by the doctor recommending a biopsy and by a breast radiologist. Together, they can decide if a surgical biopsy can be avoided, and confirm the diagnosis or remove a non-cancerous lesion performing VAB as an outpatient procedure.

The maximum size of the lesion which can be safely removed is dependent on the experience of your doctor and more so on the size of the breast, and it is around 4-5 centimeters.  The larger the breast, the larger the lesion which can be removed.

Both a vacuum assisted biopsy (VAB) and a vacuum excision of a lesion are relatively short procedures. A typical biopsy will take around 20-30 minutes. For an excision of a lesion a good rule of thumb is that it will take a little less than 10 minutes per centimeter. Given that lesion up to 5 cm can be safely removed, a vacuum assisted removal will take around 60 minutes.

You might experience a mild bruising feeling after the procedure. This will reside in 2-3 days after which you can safely resume all your normal activities.

It is possible that there is quite severe bruising visible in the breast. Don’t panic: this is normal. It will however take long, up to 8 weeks, to completely resolve.

VAB and VAE are techniques that can be used in most cases where a surgical procedure is needed to biopsy a suspicious lesion (VAB) or excise a benign lesion (VAE). However, these techniques may not be the most appropriate option in certain cases, such as:

1. For large, benign nodules, more than four or five centimeters in diameter, or nodules with hard consistency. VAB or VAE would not be indicated as it is likely that the nodules cannot be completely removed.
2. In the event of large blood vessels around the lesion. These increase the probability of bleeding if they were punctured during the procedure.
3. For lesions close to the skin, deep in the tissue, or underneath the nipple. These biopsies may be challenging to perform. Depending on the circumstances, VAB or VAE may be conducted by experienced specialists.
4. For excision of small tumors in the ducts (papilloma) that spread inside the nipple. These cases are better treated with surgery, as there is a high probability of harming the nipple.

Even though VAE is starting to be used to treat selected cases of breast cancer, this technique is not accepted yet as a valid alternative to surgery in already diagnosed cancers. Performing either VAB or VAE must be discussed in a Multidisciplinary Breast Committee in which all the specialists responsible for diagnosis and treatment are integrated. The patient should receive clear information about the advantages and disadvantages of the different approaches in her own particular case. A consensual decision taken by the Multidisciplinary Group is also required in those specific cases where the suitability of VAB or VAE might be up for debate. Patients that show an inability to collaborate during the procedure; who are unable to stay still (especially if the procedure is guided sterotactically or with MRI); or who exhibit signs of severe anxiety are typically not good candidates for VAB/VAE. These patients should be assessed individually in order to decide the best course of action and may require sedation in order to complete the procedure.