Breast Biopsy: Open

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Chapter 232 Breast Biopsy: Open

DESCRIPTION

Open breast biopsy is a technique used to obtain tissue samples for the histologic diagnosis of breast masses.

INDICATIONS

Breast mass or suspicious lesion (palpable; nonpalpable masses may be sampled if image guidance is available).

CONTRAINDICATIONS

Local skin infection, known or suspected allergy to agents used (e.g., latex, iodine). Patients who take blood thinners or aspirin should discontinue them in advance of the procedure.

REQUIRED EQUIPMENT

• Skin preparation materials (alcohol, iodine- or hexachlorophene-based antibacterial solution [e.g., Betadine, Hibiclens])

• Sterile gloves

• 1% lidocaine without epinephrine, 10-cc syringe, 22-gauge needle

• Scalpel (#15 blade) and fine tissue scissors (e.g., Metzenbaum)

• 2-0 or 3-0 absorbable undyed suture on a small to medium tapered needle and 3-0 or 4-0 absorbable undyed suture on a small cutting needle, needle holder, thumb forceps, suture scissors

• Small retractors (e.g., Senn Miller, Ragnell [Army/Navy] or similar) may be useful, especially if an assistant is available

• Electrosurgical generator, hand piece, and return electrode (“ground pad”)

• Sterile gauze pads (2″ × 2″)

• Self-adhesive skin tapes (if desired)

• Self-adhesive bandage

• Suitable tissue preservation/transportation medium (10% formalin solution or similar) (If estrogen and progesterone receptors are to be assessed, a sample of unpreserved tissue must be frozen within 30 minutes.)

TECHNIQUE

After appropriate informed consent has been obtained, the skin is disinfected and local anesthetic is injected at the chosen site. (The majority of biopsies can be performed with curvilinear incisions following the contours of the breast, often in the circumareolar area.) An open biopsy should be performed using a scalpel rather than electrosurgical energy because thermal effects on the biopsy material may blur the margin of normal tissue around the tumor and cause abnormally low receptor levels.

The dissection is carried to the area of concern through a combination of sharp and blunt techniques. A change in tissue character or a “gritty” sensation may be noticed as the tissue is dissected near some mass lesions. The mass or area of interest is excised and hemostasis is obtained through electrosurgical energy or the placement of hemostatic sutures to close dead space. The skin may be closed using a running subcuticular suture or self-adhesive skin tapes.

At the close of the procedure, samples are sent to the pathology laboratory for diagnosis and light dressing is applied. (A self-adhesive bandage often suffices.) Ice and gentle pressure may be applied for 15 to 30 minutes to minimize bruising.

It is important to send the pathology laboratory a small sample (1 g of suspect tissue) to determine the presence or absence of estrogen and progesterone receptors. These receptors are heat labile; therefore, the tissue must be frozen within 30 minutes.

Nonpalpable masses may be localized through the placement of a small needle or sterile J-wire under fluoroscopic or ultrasonographic guidance. These are then used as guides for the open dissection. The specimen is removed with the wire or needle in place, and it is radiographed to confirm the removal of the suspect area. (These techniques have been largely supplanted by computer-guided core biopsy techniques.)

COMPLICATIONS

Bleeding, hematoma, infection.

FOLLOW-UP

If nonabsorbable suture material is used to close the skin, the stitches will need to be removed during a follow-up visit. The incidence of carcinoma in biopsies corresponds directly with the patient’s age. Approximately 20% of breast biopsies in women age 50 are positive, and this figure increases to 33% in women age 70 or older.

CPT CODE(S)

19101 Biopsy of breast; open, incisional

Tafra L, Fine R, Whitworth P, et al. Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors. Am J Surg. 2006;192:462.

Bluemke DA, Gatsonis CA, Chen MH, et al. Magnetic resonance imaging of the breast prior to biopsy. JAMA. 2004;292:2735.

Chagpar AB, Scoggins CR, Sahoo S, et al. Biopsy type does not influence sentinel lymph node status. Am J Surg. 2005;190:551.

American College of Obstetricians and Gynecologists. Breast cancer screening. ACOG Practice Bulletin 42. Obstet Gynecol. 2003;101:821.

Chang DS, McGrath MH. Management of benign tumors of the adolescent breast. Plast Reconstr Surg. 2007;120:13e.

Valea FA, Katz VL. Breast diseases. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:347.

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