Surgical Biopsy - Making The Diagnosis: Breast Cancer

Content provided by the Faculty of the Harvard Medical School

Surgical biopsy

For a surgical biopsy, the surgeon makes an incision in the skin and removes all or part of the abnormal tissue for examination under a microscope. An excisional biopsy is the removal of the entire area of concern, along with a narrow margin of healthy tissue all the way around it. This is done when the abnormal area is small.

An incisional biopsy is the removal of a portion of the abnormality and is appropriate for larger lesions in order to secure a diagnosis while minimizing the effect on the breast's appearance.

Surgical biopsy can be performed under local anesthesia, intravenous sedation, or general anesthesia, depending on the doctor's recommendation and your preference. The procedure takes about an hour, and the recovery period is less than two hours.

When a breast mass or an area of calcifications cannot be felt, the surgeon may choose to use a procedure called wire localization to help identify the tissue for later surgical removal. After applying a local anesthetic, the mammographer inserts a hollow needle into the breast and, guided by ultrasound or mammography, locates the suspicious area. The mammographer inserts a thin wire with a hook on the end through the hollow needle and into the breast alongside the lesion. The mammographer then removes the needle, leaving the wire in place to serve as a guide to help the surgeon find the area of breast tissue to be excised later.

When a core needle biopsy is inconclusive, which occurs 10% of the time, a surgical biopsy provides a firm diagnosis. In addition, if a complex cyst does not completely collapse during aspiration, doctors may perform surgical biopsy to find out whether there is a cancer within the cyst.

Unlike needle biopsies, a surgical biopsy leaves a visible scar on the breast and sometimes causes a noticeable change in the breast's shape. It's a good idea to discuss the placement and length of the incision with your surgeon beforehand. Also ask your surgeon about scarring and the possibility of changes to your breast shape and size after healing.

In the case of a wire localization surgical biopsy, there is a 2% chance the surgeon will miss the site in question. Of the 20% of women who are diagnosed with cancer following an open surgical biopsy, most require a second breast surgery to make sure all the cancer tissue has been removed along with a safe margin of healthy tissue.

Women who have been diagnosed with ductal carcinoma in situ (DCIS) generally will need a more extensive surgical biopsy procedure to ascertain that all of the abnormal breast tissue has been removed and the calcifications identified have been removed. The specimen may also be marked with ink to show the orientation of the excised (surgically removed) tissue. This helps the pathologist determine whether any residual cancer was present at the cut surface (surgical margin) of the tissue. If cancer cells are present at the cut surface, additional excision may be required.

There may also be circumstances when the surgically removed specimen obtained from surgical biopsy is further evaluated with a mammogram, to determine the adequacy and accuracy of the removed tissue. The calcifications that may have been identified on the mammogram can be examined and correlated in the removed specimen.

Also some patients may need another mammogram several weeks to months after the surgical removal of the abnormality. This is done to be certain that the calcifications were removed entirely and the mammographic irregularity leading to the surgical biopsy is no longer present. If these criteria are not satisfied, an additional surgical excision may need to be performed.

As with all procedures that obtain breast tissue for diagnostic evaluation, if the mammographic abnormality was considered to be a high risk BIRADS 4 or 5, some surgeons may consider an evaluation of the lymph nodes under the armpit and if any abnormalities are detected, consider a biopsy, using fine needle aspiration or other technique, of the lymph nodes under this area.

Last updated:	April 23, 2007