Breast Surgery

Biopsy

A biopsy is a procedure performed in order to establish a diagnosis. You may have had a mammogram performed, which demonstrated an abnormality, which requires a tissue biopsy to rule out an underlying breast cancer. In the majority of instances, slightly suspicious calcifications are identified. Fortunately, the majority (~80%) of slightly suspicious calcifications that warrant a biopsy turn out to be benign. In and of themselves, calcifications are not harmful. However, depending on their appearance, their presence may suggest that there is an underlying pre-invasive (ductal carcinoma in situ) or invasive breast cancer in that region. Because early identification allows us to treat breast cancers at a much earlier stage, pursuing a tissue diagnosis is important.

Occasionally, women will present with breast masses that were discovered on examination. Masses that turn out to be solid (not a simple cyst) on radiographic studies should also be biopsied.

The types of biopsies available for breast lesions include fine needle aspiration, stereotactic or ultrasound-guided core needle biopsy, and open surgical biopsy. The goal of each type of procedure is to obtain enough tissue to establish a diagnosis.

Fine Needle Aspiration (FNA)

Dr. Maggie DiNome: Santa Monica California breast surgeon, cancer specialist, St John's Hospital This procedure is generally performed for masses that can be felt on examination. This biopsy technique involves passing a small needle directly into the mass and removing enough cells for a diagnosis. The cells are placed on a slide for the pathologist to evaluate under the microscope. The procedure takes only a few minutes, causes minimal discomfort, and can be performed with or without local anesthesia.

Core Needle Biopsy (CNBx)

Dr. Maggie DiNome: Santa Monica California breast surgeon, cancer specialist, St John's Hospital The needle used for a core needle biopsy is slightly larger than that used for a fine needle aspiration. The benefit is that pieces of tissue, rather than just cells, can be removed for diagnosis. Similar to FNA, core needle biopsy does not involve an actual surgery, so there is no significant recovery period. Core needle biopsy can be performed for palpable masses, as well as non-palpable abnormalities that are identified on mammogram or ultrasound.If you have calcifications that were discovered on mammogram, a stereotactic core needle biopsy (SCNBx) can be performed, which uses coordinates identified on your mammogram to guide the placement of the needle into the area of abnormality. Similarly, if a mass is identified on ultrasound, a core needle biopsy can be performed using the ultrasound as a guide. Both procedures are performed under local anesthesia. The benefit of these procedures is that a diagnosis can usually be established without requiring an operation. However, there are some instances when a CNBx is not technically possible, and surgical biopsy becomes indicated. In addition, there are a few instances when the needle biopsy does not yield a definitive diagnosis, and surgical biopsy is also recommended.

Dr. Maggie DiNome: Santa Monica California breast surgeon, cancer specialist, St John's Hospital An open surgical biopsy or excisional biopsy involves removing the entire lesion in order to obtain a diagnosis. Unlike a needle biopsy, an excisional biopsy involves making an incision to remove the area of abnormality. In addition, the excisional biopsy is usually performed with sedation and a local anesthetic in the operating room. A procedure called wire-localization is often necessary to guide the surgeon during excisional biopsy if the abnormality identified cannot be felt, such as calcifications found on mammogram. On the morning of the surgery, you will be seen at the Breast Center, at which time a wire will be placed into your breast to mark the abnormal area. You will then be transported to the operating room with the wire taped in place. The surgeon then uses the wire to guide the excision.

The open surgical biopsy is performed as an outpatient procedure. Because of the sedation used, you will need someone to drive you home from the hospital. You will be given instructions regarding the care of your incision and dressing. Because recovery is minimal, you may return to work the following day.

Lumpectomy

If the diagnosis of pre-invasive cancer (ductal carcinoma in situ or DCIS) or invasive cancer is made on biopsy, you will most likely require additional surgery. Because the goal of the biopsy procedure is to make a diagnosis, more definitive surgery is usually necessary for treatment. As an alternative to mastectomy, breast-conserving surgery has become more desired. A large clinical trial has demonstrated that in patients who are candidates, lumpectomy followed by radiation (or breast-conserving surgery) yields similar results to mastectomy in terms of overall survival. A lumpectomy involves removing the area of tumor and a surrounding area of normal breast tissue (considered the margin), but leaving the majority of the breast intact. In order for breast-conserving surgery to be effective, the margin must be negative. In up to 30% of cases, a second surgery for re-excision is necessary to remove additional breast tissue because tumor cells are found at the edge of the initial lumpectomy specimen, leaving a positive margin. Because microscopic tumor cells cannot be felt or visualized at the time of surgery, we have to rely on the microscopic assessment of the margins by the pathologist in order to ensure a clear margin.Depending on the size of one’s breasts, the size of the lesion, and the location of the lesion, a cosmetic deformity may result following a lumpectomy. A deformity may include a visible concavity, a reduction in breast size, alteration of the shape of the breast, etc. In many cases, the deformity improves with time once all of the post-operative changes subside. This is also true of the effects of radiation on the appearance of the breast.In some cases, breast-conserving surgery is not the most appropriate operative treatment. Simple mastectomy for DCIS or a modified radical mastectomy for breast cancer still has a role in the treatment of breast cancer. Specifically, breast-conserving therapy would be contraindicated for patients who:

- Have already had radiation to the affected breast or chest

- Are pregnant and would require radiation while still pregnant

- Have certain medical illnesses (eg. scleroderma) that would preclude the use of radiation

Breast-conserving therapy may not be appropriate for patients who:

- Have large lesions relative to breast size, in which a lumpectomy would have unacceptable cosmetic results

- Are unable to achieve a negative margin after repeated excisions

Mastectomy

A simple mastectomy involves removing the entire breast, including the nipple and areolar complex, but not removing any lymph nodes from the armpit. This procedure is appropriate for DCIS, which does not spread to the lymph nodes. In addition, some patients may elect to have a preventative mastectomy because of a strong family or personal history of breast cancer. This would also be a simple mastectomy.

A modified radical mastectomy removes not only the entire breast, but also the lymph nodes in the armpit. This procedure is performed for breast cancer. You have three levels of lymph nodes underneath the arm, and levels I and II are routinely removed during modified radical mastectomy. Because the majority of lymph nodes are removed, patients have a risk of developing arm swelling following this procedure. The majority of patients have only minor swelling, which can be managed easily, but a small percentage (~5%) develop more disabling swelling. A referral to a lymphedema specialist is sometimes recommended.

For both simple and modified radical mastectomy, drains are left in place after the operation. These drains are necessary to remove the extra fluid that develops in the chest wall and armpit after surgery. You will have been instructed regarding proper drain care prior to your discharge from the hospital. The drains will then be removed in the office in approximately 1-2 weeks.

Lymph node surgery

When a patient is diagnosed with breast cancer, it is important to determine whether or not the cancer has spread to the lymph nodes. If cancer is found within the lymph nodes, then we generally recommend chemotherapy to help fight any potential circulating tumor cells that may have migrated from the breast.

The most advanced and up-to-date method of sampling lymph nodes is the sentinel lymph node biopsy. This is a relatively new procedure that has gained acceptance as a reliable and lower risk procedure for adequately determining the status of the lymph nodes. The procedure should only be performed by surgeons trained in this technique. Dr. DiNome is well-trained in the sentinel lymph node biopsy procedure.

Sentinel lymph node biopsy involves removing only the first lymph node(s) in the armpit into which the tumor drains. Usually, 1-3 sentinel lymph nodes will be identified. The procedure involves receiving an injection of a radioactive isotope into the breast in the area of the cancer on the morning of surgery by a nuclear medicine radiologist. An x-ray picture is then taken to verify that the radioactivity has migrated to the armpit. Once you reach the operating room, the surgeon will inject a blue dye around the tumor site as well. Using both the blue dye as a visual marker, and the radioactive isotope as an audible marker, the surgeon is able to identify the lymph node(s) that have taken up the dye and radioactive tracer. These lymph nodes are termed the sentinel nodes, and these nodes are removed.

If the sentinel lymph nodes are found to be negative, then this is a reasonable indicator that the rest of the lymph nodes in the armpit are also negative, and no additional lymph node surgery is necessary. If tumor cells are found within any of the sentinel nodes, then a complete axillary dissection is indicated at this time. Ongoing investigation may make axillary dissection obsolete in the future, but it is still has a role in the treatment of breast cancer today. Because only a few lymph nodes are removed during the sentinel node procedure, the risk of arm swelling is minimal.

Axillary dissection involves removing the lymph nodes in the armpit. Typically, 10-20 lymph nodes are removed. On occasion, a sentinel lymph node biopsy is not technically possible or an axillary dissection is performed in conjunction with a modified radical mastectomy. Or, as mentioned above, tumor may be found in the sentinel nodes, necessitating an axillary dissection. Because a larger number of lymph nodes are removed during axillary dissection, the risks are higher. Some patients will also experience a temporary numbness in their upper arm, which can remain for up to one year.


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