Chapter 44 Breast Biopsy and Breast-Conserving Surgical Techniques

INTRODUCTION

Surgical procedures of the breast have changed significantly since the late 1990s. With improved imaging techniques, the detection of radiologic abnormalities is increasing and the size of detected malignancies is decreasing. These factors have led to a shift in management strategies toward more precise and aesthetic surgical approaches. Just as the surgical management has changed, so have other subspecialty management strategies such that the multidisciplinary aspect of breast cancer has become more complex. Comprehensive care, therefore, involves surgical strategies and decisions with input from a team of multidisciplinary specialists. The operating surgeon’s first and crucial step to avoid surgical pitfalls with the breast patient is to ensure easy and frequent communication with the other specialists. A strategy used by many centers to ensure this communication is the multidisciplinary tumor board.

A significant change in breast surgery was the shift from open surgical biopsy to image-guided needle-core biopsy (for the diagnosis of breast abnormalities). The current literature supports the superiority of an image-guided needle biopsy over an open surgical biopsy for the vast majority of patients with a breast abnormality.¹^–⁷ This technology has decreased the frequency of operative procedures, allowed for tailored care of proven malignancies, and improved the accuracy of definitive surgical management of breast cancer. It is also convenient for the patient and expedites the diagnosis. A very small group of patients remain who present with a palpable abnormality, with no imaging correlate, who will still require an open surgical biopsy for a definitive diagnosis.

The vast majority of patients who do need to go to the operating room for a diagnosis (1) are being evaluated for a nonpalpable, image-detected lesion for which the core biopsy pathology result is equivocal or (2) were constrained by the limitations of the image-guided techniques (e.g., thin breast, very faint microcalcifications).

Partial mastectomy, which is also commonly referred to as lumpectomy, is the breast-conserving surgical procedure performed for a breast cancer. Although many of the steps of a lumpectomy are similar to those of a biopsy, the goals of each are very different and are considered separately.

Breast Biopsy

Lesions that are not palpable require some form of localization. This is an active area of investigation because this scenario continues to increase in frequency.⁸ Wire localization has been the standard procedure for localizing a lesion for the surgeon since its introduction in the 1980s,⁹^–¹¹ but there is much room for improvement. Standard wire localization is frequently imprecise. In addition, when addressing a malignancy, it does not assist with obtaining negative margins and is not very convenient for the patient who must endure an additional procedure prior to the initial surgery. It has typically been performed outside of the operating room by the radiologist, but fortunately with increasing use of ultrasound by surgeons, a shift is occurring, allowing the patient to be localized in the operating room. Intraoperative localization has many advantages: it avoids the time delays that come with coordination of a second department; scheduling is simplified; patient satisfaction is maximized; staff inconvenience is minimized; and finally, the accuracy is probably better when the physician localizing the lesion is also removing it.

The precision and accuracy of the localization of the lesion are far more important than who performs it. The worst consequence of inadequate localization is missing the lesion and having to return the patient to the operating room for a second attempt at excision. This is obviously disconcerting to the patient, but it also delays the diagnosis and potential treatment. In addition, because cosmesis is related to the amount of tissue removed, a second trip to the operating room to remove more tissue could negatively affect cosmesis, patient satisfaction, and future imaging.

Grade 3 complication

• Prevention

The localization procedure needs to adhere to the following basic principles, whether performed by the radiologist or the surgeon:

1. Ensure that the correct area has been targeted, and if a clip is the target, that the clip has, in fact, remained at the area of interest since the time of needle biopsy.

2. Ensure that the site of the wire entering the skin has been marked with a marker visible in the postlocalization films (if the localization is done by someone other than the surgeon) and that another point of reference on the breast (most commonly, the nipple) is also marked so that the surgeon can determine how far the lesion is from the entry of the wire through the skin and within the breast tissue.

3. Ensure that the location of the wire is within 2 to 3 mm of the clip (if a clip is targeted).

4. Ensure that two views (both the craniocaudal [CC] and the mediolateral [ML]) have been obtained and sent with the patient to confirm that the locations of the lesion, the clip, and the wire can be determined by the surgeon.

Once this has been established, it is the surgeon’s goal to remove the area of concern. If the target is a clip or calcifications or if the lesion remains nonpalpable even with dissection down to the area, a specimen radiograph is needed. If there has been clip migration or if the localization is not where the surgeon believes the original lesion is, it is imperative that good communication occurs between the radiologist and the surgeon prior to the procedure. In these cases, retrieval of the clip on specimen radiograph may not be necessary. If the lesion becomes palpable with dissection, a specimen radiograph need not be performed if the operating surgeon is confident the lesion has been obtained. Caution should be exercised with this approach, however, because a palpable hematoma from the prior core biopsy may masquerade as the lesion.

Once the best determination of the site of the lesion is made based upon direct review intraoperatively of the mammographic or ultrasound images, the lesion is marked and the incision is placed directly over the abnormality. Occasionally, the more cosmetic periareolar incision is used, especially if the lesion is in close proximity to the nipple-areolar complex. Dissection then proceeds toward the wire. The wire is then delivered into the wound. Palpation of the tissue surrounding the wire will ensure an adequate removal of the tissue that needs further assessment. It is worth emphasizing that the incision usually is not placed at the site of the entrance of the wire to the skin. If the lesion is localized by the surgeon in the operating room, the surgeon must have prior, precise knowledge of the lesion’s location. It is best if the surgeon retains a copy of the ultrasound or mammogram for reference in the operating room. The use of intraoperative ultrasound is justifiably increasing. If a lesion is visible on ultrasound and the surgeon has ultrasound skills, localization in the operating room is easier and safer, requires less time, and is more convenient for the patient and surgeon.

With experience, localizing a lesion in the operating room is usually straightforward, but it can be challenging with small lesions. If the lesion is small (<5 mm), consideration should be given to having the patient’s breast marked preoperatively by another physician (surgeon or radiologist) to get consensus by two physicians of the lesion’s location. Sometimes, after a core biopsy, a hematoma is well visualized, but with time, it resolves, leaving little at the site of the biopsy. If the surgical procedure is to be scheduled more than a few weeks after the core biopsy, consideration should be given to performing a repeat ultrasound to ensure the surgeon can still visualize the lesion in the absence of the hematoma. Clips placed at the time of core biopsy have, in the past, not been echogenic enough to visualize with ultrasound. However, the newer clips retain materials around the clip itself that can be seen by a surgeon experienced with ultrasound. Use of these types of clips can also increase the number of patients who are candidates for localization in the operating room.

A number of standard localization devices are on the market (Kopans [Cook, Bloomington, IN]), Hawkins (Boston Scientific, Watertown, MA [Fig. 44-1]), and Bard (CR Bard, Inc., Covington, GA), but new devices are being introduced in an attempt to solve the inherent problems of the traditional needles. The Anchor Guide (SenoRx, Aliso Viejo, CA [Fig. 44-2]) is a device that uses an umbrella basket–type deployment that creates a palpable lesion from a nonpalpable lesion, assisting in localization and resection.¹²