Chapter 44 Breast Biopsy and Breast-Conserving Surgical Techniques
INTRODUCTION
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.
Breast Biopsy
INDICATIONS
OPERATIVE PROCEDURE
Marking the Lesion
Failure to Remove the Correct Area of Concern
• Consequence
Adequate Localization
Failure to Remove the Correct Area of Concern
• Consequence
• Prevention
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.
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
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