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Background/Objective: Core needle biopsy (CNB) was widely used in the diagnosis of ultrasound-detectable breast lesions. We aimed at assessing the diagnostic performance differences between 14- and 16-gauge ultrasound-guided core biopsies. Methods: This retrospective study enrolled patients receiving CNB from January 2001 to December 2007. The results of 14- and 16-gauge breast CNBs were compared with pathology reports of open surgical biopsy (OSB). Results: A total of 1024 paired CNB and OSB results were obtained from 1732 CNB procedures in 1630 patients.Those CNB results reached 92.9% sensitivity, 99.7% specificity, 5.96% underestimation, and 94.8% accuracy rates. There was no difference in sensitivity (p = 0.17) or specificity (p = 0.38) between 14- and 16-gauge needles. However, better overall accuracy (p = 0.02), less underestimation (p < 0.001), and lower false-negative (p = 0.02) rates were found for the 14-gauge CNB. Conclusion: Regarding accuracy and underestimation rates, a 14-gauge needle is preferred to a 16-gauge one in ultrasound-guided biopsies.