Localization Biopsy of Mammographically Detected Lesions

Description

General anesthesia is usually used, but local anesthesia and IV sedation may be

used. A mammographic or ultrasound image-guided localization and excisional

breast biopsy is indicated for a non-palpable mammographically detected lesions,

architectural distortion, or suspicious microcalcifi cations.

The localization can be achieved by a hookwire or using a carbon track, both being placed using a needle

and MMG or U/S, to locate and mark the lesion (Fig. 2.1 ).

Fine-needle or core-needle biopsy should be obtained prior to operation, if possible,

to permit better operative planning and margin consideration. Often a cancer

operation rather than a diagnostic procedure can be performed, perhaps sparing the

patient two operations. Rarely, two wires or carbon markings are used to defi ne

large lesions.

The incision chosen may be peri-areolar, curvilinear, horizontal, or even radial

according to the lesion location, marker, and desired cosmesis. Dissection usually

aims to excise a margin of normal tissue around the lesion and hookwire/carbon

marker, often including pectoral fascia. Radioactive seed implantation under mammographic

control has also been used. Electrocautery and deep, absorbable suture

closure is used for hemostasis, often avoiding wound drains. Marking sutures

are usually used to orientate the specimen to defi ne pathological margins. Once

the specimen is removed, a specimen radiograph is performed to compare to the

original fi lm and determine completeness of excision and radiological margins.

Anatomical Points

The anatomical base of the breast extends from the inferior clavicle to the inframammary

fold and from the lateral sternum into the axilla. Occasionally, islands

of breast tissue exist in the axilla, isolated from the axillary tail. The nipple-areolar

complex and main breast mass may vary considerably between individuals, with

age and posture. A breast mass can be located anywhere within the breast. The size

and nature of the mass and breast essentially determines the placement and type of

incision, surgical result, and cosmesis. The possibility of mastectomy or further surgery

is often a consideration in preoperative placement of incision. Care should be

taken to avoid downward repositioning of the nipple with large excisions of lower

pole breast tissue. This deformity may be avoided by mobilizing nearby normal

breast tissue into the area of the defect.

Perspective

See Table 2.2 . Complications overall are not very common. Development of a large

postoperative hematoma is a signifi cant complication (Figs. 2.2 and 2.3 ). Infection

and prolonged drainage can be signifi cant and may result in cosmetic problems.

Failure to diagnose the abnormality can also occur. Cosmetic defects are rarely

troublesome. However, all may require further surgery and this can be signifi cant,

resulting in further hospitalization.

Often, after surgery a mass may be palpable due to scarring and seroma formation

and may persist for up to 6 months postoperatively while the scar is remodeling.

There is often some temporary paresthesia over the incision. Many patients

describe it as burning or shooting pain. Acute postoperative pain is usually managed

well with oral pain medication and resolves after a couple of days. Chronic

pain is rare.

Major Complications

The major risks are development of a large postoperative hematoma or infection.

These complications are rare and can be avoided with careful hemostasis. 

Large hematomas may require surgical evacuation, otherwise infection and spontaneous

drainage may occur. Draining of infected hematomas can lead to open wounds that

last for months. Dense fi brous breast tissue can make localization and excision diffi

cult. Occasionally, the localization hookwire or carbon mark is inaccurate or displaced,

leading to failed biopsy. Failure to diagnose due to inadequately sampling a

non-palpable lesion, biopsying the wrong area, or incomplete excision, is not very

common with a localization biopsy, but may necessitate another localizing procedure

and further surgery. Removal of the lesion may be confi rmed using a specimen

MMG or U/S.

If skin fl aps are raised to remove a superfi cial mass, care should be taken not to

make the fl aps too thin, causing reduced blood supply to the skin, resulting in necrosis,

tissue loss, or skin dimpling. Extensive skin necrosis may require dressings and/

or excision and skin fl ap repair.

Consent and Risk Reduction

Main Points to Explain

• GA risk

• Wound infection

• Bleeding/hematoma

• Abscess formation

• Cosmetic deformity

• Further surgery