A bilateral breast exam should be performed in all patients for whom wire-localized breast biopsy is being contemplated for two reasons. First, to assess whether or not the lesion is truly nonpalpable. If the abnormality is palpable, then wire localization will not be necessary. If an abnormality is palpated, it is critical to review with the radiologist to be sure that the palpable abnormality corresponds to the imaging abnormality being recommended for biopsy. The second reason for bilateral breast examination is to make sure there are no other palpable occult abnormalities that may also require biopsy.

For patients with biopsy-proven cancer who are to undergo wire-localized lumpectomy, a thorough history and physical examination is necessary to make sure they are suitable candidates for breast conservation therapy (BCT). Contraindications to BCT include prior radiation, collagen vascular disease, first or second trimester of pregnancy, multicentric cancer, or widespread calcifications (see Part 5, Chapter 5, Lumpectomy).

The preoperative imaging is essential to the procedure. Prior to the decision to perform a wire-localized breast biopsy, the breast imaging should be reviewed to determine whether the patient is a suitable candidate for an image-guided biopsy, as this is the preferable first step. The patient’s allergies, medications (specifically aspirin or anticoagulants), or the presence of a bleeding diathesis should be reviewed. Contraindications to stereotactic core needle biopsy include an inability to adequately visualize the target lesion or an inability of the patient to remain in the position required for the procedure. Some patients may exceed the weight limit for the stereotactic table. Other factors that may preclude stereotactic core needle biopsy include higher breast density; lesions close to the skin, chest wall, or axilla; or the presence of breast implants.

Prior to coming to the operating room (OR), the patient undergoes needle localization under image guidance. After local anesthesia, a rigid introducer needle with a hooked wire within it is directed toward the site of the abnormality using biplanar mammography (FIG 1A) or ultrasound (FIG 1B). The rigid needle is then removed, leaving the wire secured by the hook so it is not easily withdrawn or redirected (FIG 2A,B).

In many cases, a wire-localized excision is recommended after an image-guided core needle biopsy-demonstrated atypia (lobular carcinoma in situ [LCIS], atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], or flat epithelial atypia [FEA]). It is also often recommended after a needle biopsy of papilloma or radial scar. In these cases, a fraction may upstage to in situ or invasive cancer.^{1, 2, 3, 4, 5, 6} It is good to review the pathology and indications for the biopsy prior to the procedure.