Open Biopsy Open biopsy may be performed if the lesion cannot be successfully biopsied with a needle, or if FNAC or CNB has shown a lesion that may be associated with malignancy, such as atypical ductal hyperplasia (ADH) or lobular carcinoma in situ (LCIS). Excision must be performed if the results with needle biopsy are equivocal or discordant with the clinical findings. An unequivocal histologic diagnosis of cancer should be obtained before treatment of breast cancer is undertaken. Cytologic diagnosis may be relied on if the mass clinically or mammographically appears to be malignant.
Open biopsy can be performed in the outpatient setting with local anesthesia in the following manner (although this technique largely is replaced by core biopsy and usually is not necessary): 1.
The patient is positioned and the location of the mass confirmed.
2.
Local anesthesia is used to infiltrate the skin and subcutaneous tissue surrounding the palpable mass.
3.
The skin in incised directly over the mass. Placement of this incision is critical. It should be situated in such a way that it can be excised with an ellipse of skin should the patient require a subsequent mastectomy, or placed cosmetically so that partial mastectomy can be performed successfully through it. Para-areolar incisions are appropriate only for lesions in proximity to the nipple–areolar complex.
4.
The mass is gently grasped with Allis forceps or with a stay suture and moved into the operative field.
5.
The mass should be excised completely whenever possible. Larger lesions that are difficult to totally excise can be incised for diagnostic purposes only. When an incisional biopsy is performed, a frozen section should be obtained to confirm that appropriate tissue for diagnosis is present. Such masses are preferably sampled with FNAC or CNB, with incisional biopsy rarely, if ever, indicated.
6.
Once the mass is removed, hemostasis is achieved and the incision is closed. A cosmetically superior result will be achieved if the deep breast parenchyma is not reapproximated. The most superficial subcutaneous fat can be reapproximated with fine absorbable sutures, and the skin can be closed with a subcuticular suture and adhesive strips.
Biopsy of nonpalpable lesions is a potentially difficult procedure that requires close cooperation between the surgeon and radiologist. Using ultrasonographic, mammographic, or MRI guidance, a needle or specialized wire is placed into the breast parenchyma at or near the site of the suspected abnormality. Some mammographers will inject a biologic dye into the breast parenchyma to assist localization. The surgeon reviews the films and localizes the abnormality with respect to the tip of the wire or needle. Alternatively, the surgeon will perform ultrasonography intraoperatively to directly localize the lesion. An incision is made directly over the abnormality, and a small portion of the breast tissue suspected of containing the abnormality is excised. For mammographically detected lesions, a specimen radiograph is obtained to ensure that the abnormality has been recovered. Often, the radiologist can place a needle in the specimen at the site of the abnormality to facilitate histologic evaluation and ensure that the pathologist examines the site of the abnormality. Image-guided biopsy should be performed only for lesions inaccessible to needle biopsy or those lesions that may be associated with malignancy such as ADH.
Breast cancer may arise in the intermediate-size ducts, terminal ducts, or lobules. In most cases, the diagnosis of lobular and intraductal carcinoma is based more on histologic appearance than site of origin. The cancer may be either in situ (ductal carcinoma in situ or lobular carcinoma in situ) or invasive (infiltrating ductal carcinoma, infiltrating lobular carcinoma). Morphologic subtypes of infiltrating ductal carcinoma include scirrhous, tubular, medullary, and mucinous carcinoma.