Produced by the Royal College of Physicians of Edinburgh and Royal College of Physicians and Surgeons of Glasgow

Image-guided Breast Biopsy

  • Dr G Ralleigh, Consultant Radiologist, Kings College Hospital, London, England


In a high-profile English legal case, an NHS Trust was found guilty of providing misleading and negligent advice after a breast biopsy in the case of a patient who subsequently died from breast cancer. Dr Gita Ralleigh reviews this case, the image-guided biopsy procedure and the extent to which hospitals should track patients following biopsy.

Key Points

  • A patient underwent a breast biopsy which was reported as indeterminate. She declined a further biopsy and failed to attend at two hospital appointments.
  • A judge found the hospital in breech of its duty to the patient, as staff had ‘failed to advise her adequately of the risks she faced, the options open to her and their respective merits’.
  • Image (ultrasound or X-ray) – guided biopsy is now favoured generally for breast lesions, and in about 2·8% (0·3 8·2%) of cases a cancer is missed.
  • Avoiding missed cancer involves using optimal biopsy technique, and correlating clinical, imaging and histological findings to identify likely missed lesions.
  • The radiologist doing the biopsy and the referring clinician (usually a breast surgeon) have the duty of informing the patient of the biopsy results and of discussing their implications and any requirements for treatment.

Declaration of interests: No conflict of interests declared

In the autumn of 2004 the case of Helen Cooper vs Royal United Hospital Bath Trust was widely reported in the national press. Mrs Cooper was ruled by Mr Justice Butterfield to have been given ‘negligent’ and ‘misleading’ advice following a breast biopsy procedure in July 2000. The results of the procedure were ‘indeterminate’ and the patient was informed that she would require a further biopsy. The hospital’s plea that Mrs Cooper had declined a further biopsy and had missed two hospital appointments was rejected. The judge ruled that the Royal United Hospital Bath NHS Trust was in breach of its duty towards Mrs Cooper saying staff had ‘failed to advise her adequately of the risks she faced, the options open to her and their respective merits’. Mrs Cooper’s breast cancer was eventually diagnosed in May 2002 and she died in September 2004 with widespread metastatic disease. The judge said the question of whether any breaches he had found were ‘causative of any loss or damage’ sustained by Mrs Cooper and her widower ‘is for another day’. The trust’s chief executive, Mark Davies, responded ‘I am determined that if there are any lessons to be learned we will learn them, but I am confident this was an unusual and tragic one-off case.’

Image-guided percutaneous breast biopsy is increasingly preferred to surgical biopsy for the histological assessment of both non-palpable (usually screen-detected) and palpable (usually symptomatic) breast lesions. Fine needle aspiration cytology has now been replaced by 14-gauge needle automated core biopsy at most centres because of its better characterisation of benign and malignant pathology and lower frequency of insufficient samples.

Ultrasound guidance or X-ray guidance (stereotactic biopsy) may be used to target the lesion depending on the nature of the abnormality. Radiologists perform most breast biopsies, although in some centres breast surgeons, breast physicians or radiographers also undertake these procedures.

The patient care advantages of percutaneous breast biopsy include fewer surgical procedures, less scarring and deformity, ease of performance and low complication rate.1 In follow-up studies the rate of missed carcinomas is low, averaging 2·8% (range 0·3 8·2%) with approximately 70% of missed cancer identified shortly after biopsy (immediate false negatives) and 30% identified subseq