(With or Without Preoperative Needle Localization)

For our surgical team, a surgical, excisional biopsy is considered a lumpectomy. This clearly means we plan to perform a surgical biopsy using the same guidelines for margin clearance that we use for a lumpectomy. In addition, we have standardized the surgical technique so that all our breast biopsies/ lumpectomies be performed using a standard, uniform protocol.

Definition of Clear Margin Status

Most surgeons are using a 2 to 5 mm margin (rim of normal-non malignant tissue) around the malignant site. However the literature reports some authors and studies are using a non-transected tumor margin as clear margin. Most surgeons believe the accurate documentation of clear margin status is essential when performing a lumpectomy. Any questionable margin should be re-excised.

Indications

1. Need of tissue diagnosis with 100 % accuracy for breast masses.

2. Need of tissue diagnosis for suspicious breast masses or mammographic breast lesions.

3. Excision of breast masses in cancerphobic patients.

Anesthesia

General or Local Anesthesia (Surgeon's preference)

The Technique

• STEP 1: Unequivocally Identifying the Breast Lesion To Be Excised-If it is a palpable lesion it should be defined accurately. If it is a mammographic lesion, a preoperative needle localization should be performed. If an ABBI Device is used to excise the mammographic lesion, a stereotactic localization should be performed (Refer to the ABBI Chapter).

• STEP 2: Planning the Biopsy and the Initial Incision-Preferably a periareolar incision should be made, as it has the best cosmetic results. If not feasible, the incision should be planned properly and always made in a circular fashion around the nipple-areolar complex. In addition, the surgeon should always take into consideration the posssibility of a mastectomy as the next therapeutic step. Thus the biopsy incision should always be within the island of skin to be resected with the mastectomy.

• STEP 3: Making the Incision -The incision is made with a plain scalpel.

• STEP 4: Identifying the Lesion- The lesion should be clearly identified. If a preoperative localization was performed, the preoperative mammogram should be checked to verify the position of the tip of the wire (the hook) and the specimen. Again, the surgeon should attempt to maintain a 1 cm clear margin ring around the specimen. The specimen is grasped with a Lahey clamp. A wide excision is performed.

• STEP 5: Removing or Orienting the Specimen-The specimen is amputated from the breast tissue and immediately oriented by placing two 3.0 Silk sutures. The first suture, the LONG SUTURE, is placed on the lateral aspect of the specimen. The second suture, or the SHORT SUTURE, is placed on the superior aspect of the specimen.

• STEP 6: (For Mammographic Lesions) Verify the Specimen Has Been Excised-A comparison mammogram is obtained and the presence of the specimen is verified by our staff radiologist.

• STEP 7: The Initial Pathological Analysis-We require a frozen section on these excised specimens, even though many oncologist surgeons do not. The specimen is handled by the pathologist in a very standardized manner (Refer to the pathological specimen handling section). Once the margins are inked, the frozen section is performed and an initial diagnosis may be obtained. Attention is given to the margins of the surgical specimen. The pathologist informs us of his initial impression on the margins. Any unsafe margins, will require a re-excision of the area. The specimen of margin re-excision should have the new margin marked.

• STEP 8: Closing the Incision-The incision is closed. The breast parenchyma is approximated if necessary with 3.0 Vicryl sutures. The skin edges are always approximated with a subcuticular 4.0 Maxon or PDS suture, reinforced with steristrips.

• STEP 9: If an Axillary Dissection Is Planned

CLICK HERE TO VIEW THE TECHNIQUE: AXILLARY DISSECTION

CLICK HERE TO VIEW THE TECHNIQUE: SENTINEL LYMPHADENECTOMY

Technical Notes for Excisional Biopsy-Lumpectomy

• Protocol: Cannot accurately confirm the presence of the suspicious mammographic lesion in the specimen . The following steps should be performed: 1) Wide excision of the area, 2) Comparison Mammogram on excised specimen, 3) Terminate the procedure, 4) Notification of the patient, 5) Repeat clinical exam every two months, 6) Repeat a unilateral mammogram in four months.

• Protocol: Breast deforming excisional biopsy-The surgeon should always evaluate if a superior cosmetic result may be achieved with a total or a modified radical mastectomy with possible reconstruction.

• Protocol: Malignant Lesion Involving the Nipple-Areolar Complex-When a malignant tumor is found at the time of the excisional biopsy or the lumpectomy to have invaded the Nipple-Areolar complex, it is our opinion a lumpectomy with good cosmetic results is no longer feasible. Indeed the Nipple-Areolar complex needs to be removed to achieve clear margins. We strongly believe these patients are better served with a simple mastectomy or a modified radical mastectomy (with or without a sentinel lymphadenectomy) with possible reconstruction.

• Protocol: Multicentric Carcinoma of the Breast-This type of cancer is defined by identifying at least two different foci of cancer in two different quadrants of the breast. These patients should undergo a total excision of the breast tissue or a modified radical mastectomy.

• Protocol: Post-chemotherapy Resectable, Large Tumors of the Breast-Patients with large tumors of the breast, i.e. stage III Breast Carcinoma, may experience a dramatic reduction of the size of the malignant breast mass post-chemotherapy. In some cases, these lesions can be converted to resectable lesions with lumpectomy. Although no increase in survival has been demonstrated, this alternative is often used.

References:

• Spivach B et al: Margin status and local recurrence after breast conserving surgery. Arch Surg 1994: 129:952-6

• Ghossein NA et al. Importance of adequate surgical excision prior to radiotherapy in the local control of breast cancer in patients treated conservatively. Arch Surg 1992,127:411-5

• Guenther JM et al: Feasibility of breast conserving surgery tehrapy for younger women with breast cancer. Arch Surg 1996,131:632-6

• Dewar Ja et al: Local relapse and contralateral tumor rates in patients with breast cancer treated with conservative surgery and radiotheraphy. Cancer 1995,Dec,76:2260-5