Overview
Definition:
Excisional biopsy is a surgical procedure to completely remove a palpable breast mass and a margin of surrounding tissue for histological examination
It is performed to obtain a definitive diagnosis and to remove benign lesions or to resect malignant tumors, serving both diagnostic and therapeutic purposes.
Epidemiology:
Palpable breast masses are common in women, with a significant proportion being benign (e.g., fibroadenomas, cysts, fibrocystic changes)
Malignancy rates in palpable masses vary by age, with higher likelihood in postmenopausal women or those with specific risk factors
Excisional biopsy is a cornerstone in the evaluation of such masses.
Clinical Significance:
Accurate diagnosis of a palpable breast mass is critical for appropriate management and patient outcomes
Excisional biopsy provides definitive histological diagnosis, differentiating benign conditions from breast cancer, thereby guiding further treatment strategies, preventing delayed diagnosis of malignancy, and offering symptomatic relief for benign lesions.
Indications
Indications For Biopsy:
Suspicion of malignancy based on imaging (mammography, ultrasound, MRI) or clinical examination
Palpable masses that are persistent, growing, or symptomatic despite initial investigation
Lesions that cannot be definitively diagnosed by less invasive methods (fine needle aspiration cytology, core needle biopsy)
Removal of cosmetically significant or symptomatic benign lesions like large fibroadenomas.
Contraindications:
Absolute contraindications are rare, but severe coagulopathy or systemic illness precluding surgery are relative contraindications
Local infection at the biopsy site is a contraindication that requires treatment before proceeding.
Preoperative Assessment:
Thorough clinical history including risk factors for breast cancer, menstrual history, previous breast conditions, and family history
Comprehensive breast examination to document the size, location, mobility, and characteristics of the mass
Review of previous imaging studies and pathology reports
Informed consent must be obtained, explaining the procedure, risks, benefits, and alternatives.
Surgical Procedure
Anesthesia:
Local anesthesia with or without sedation is commonly used for excisional biopsies of palpable masses
General anesthesia may be indicated for larger masses, deeper lesions, or in patients who cannot tolerate local anesthesia.
Surgical Technique:
The incision should ideally follow Langer's lines or be placed in the inframammary fold or areola for cosmetic reasons, depending on the mass location
The mass is dissected from surrounding tissue, ensuring adequate margins of healthy tissue are included with the specimen
Hemostasis is meticulously achieved using electrocautery or ligatures
The specimen is oriented by the surgeon (e.g., by pinning or marking) for accurate margin assessment by pathology.
Specimen Handling:
The excised specimen is immediately sent to the pathology department
Crucially, the specimen should be marked or inked to allow the pathologist to assess all margins accurately
For suspected malignancy, orientation marks (sutures or needles) are essential
Gross examination by the surgeon before sending to pathology can confirm removal of the palpable lesion.
Postoperative Care
Wound Care:
The incision is typically closed in layers using absorbable sutures for subcutaneous tissue and non-absorbable or absorbable sutures for skin
A sterile dressing is applied
Patients are instructed on wound care, including keeping the area clean and dry, and signs of infection to report.
Pain Management:
Postoperative pain is usually mild to moderate and managed with oral analgesics like paracetamol or NSAIDs
Longer-acting local anesthetics may be infiltrated at the time of surgery for sustained pain relief.
Activity Restrictions:
Patients are advised to avoid strenuous activity, heavy lifting, and exercises that strain the chest wall for a period of 1-2 weeks to promote healing and minimize complications like seroma formation or wound dehiscitation.
Follow Up:
Follow-up appointments are scheduled to assess wound healing, remove skin sutures (if non-absorbable), and discuss the final histopathology report
Further management depends on the diagnosis.
Histopathology And Diagnosis
Importance Of Histology:
Histopathological examination is the gold standard for definitive diagnosis of a breast mass
It determines whether the lesion is benign, premalignant, or malignant, and provides crucial information about tumor type, grade, and receptor status for malignant lesions.
Benign Lesions:
Common benign diagnoses include fibroadenoma, fibrocystic changes, phyllodes tumor, papilloma, adenosis, and fat necrosis
These often require no further treatment beyond biopsy unless symptomatic or very large.
Malignant Lesions:
Malignant diagnoses include ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), and other rarer types
If malignancy is found, further surgical management (e.g., lumpectomy with wider margins, mastectomy) and adjuvant therapy will be planned based on the specific cancer characteristics and staging.
Complications
Early Complications:
Hematoma or seroma formation at the biopsy site
Wound infection
Pain and discomfort
Minor bleeding.
Late Complications:
Scarring and cosmetic deformity
Numbness or altered sensation around the scar
Recurrence of benign lesions if not completely excised
Psychological distress related to the diagnosis.
Prevention Strategies:
Meticulous surgical technique with adequate hemostasis
Proper wound closure and sterile dressing
Antibiotic prophylaxis in select cases
Careful patient selection and counseling
Accurate orientation of the specimen for complete margin assessment.
Key Points
Exam Focus:
Understanding indications for excisional biopsy vs
core biopsy
Importance of specimen orientation and margin assessment
Histopathological correlation
Management of common benign and malignant breast lesions identified post-excision
Differentiating benign from malignant presentations.
Clinical Pearls:
Always attempt to excise palpable masses, especially if imaging is suspicious or diagnosis is uncertain
Ensure adequate margins are taken for suspected malignancy
Communicate clearly with the pathologist about specimen orientation
Counsel patients on potential scarring and cosmetic outcomes.
Common Mistakes:
Inadequate margin excision leading to positive margins for malignancy
Failure to orient the specimen correctly
Misinterpreting fine needle aspiration (FNA) or core biopsy results as definitive without excisional biopsy when indicated
Not considering patient's psychological impact of diagnosis and surgery.