Purpose This review aims to discuss the methodological aspects of dedicated molecular breast imaging (MBI) using 99m Tc-sestamibi as radiotracer to guide biopsy of occult or unclear breast lesions on mammography (MG) and ultrasound (US) that are suspicious on MBI (BI-RADS criteria 4 and 5), including its advantages, limitations and future clinical applications. Methods Literature search was performed using the PubMed/MEDLINE database and '' 99m Tc-sestamibi'', ''biopsy'' and ''breast cancer'' as keywords. The search was restricted to English language.Results There are few studies on 99m Tc-sestamibi guided biopsy methods; to our knowledge, no full studies have yet been reported on clinical validation of this new biopsy procedure. This review describes technical aspects of 99m Tc-sestamibi guided biopsy and discusses the advantages and limitations of this procedure in comparison with MG, US and MRI-guided biopsy. Conclusions MBI-guided biopsy appears to be a complementary modality and is principally indicated in the case of occult or unclear breast lesions on MG/US, that are suspicious on MBI. The future indication is in targeted biopsies in patients with large heterogeneous tumours. Further studies are needed to define the accuracy of this biopsy procedure.