An excisional biopsy is a surgical procedure performed under a general anaesthetic in which a small lump or an imaging abnormality is excised from the breast.
In contrast to surgery for breast cancer, the procedure involves removing the abnormality only. A margin of tissue is not required around the lump/imaging abnormality.
Indications for open surgical excisional biopsy: A lump that the doctor is concerned about; a lump that looks abnormal/indeterminate/suspicious on imaging; a lump that the patient wishes to have excised; an imaging abnormality which cannot be felt, this can be a mass lesion or microcalcification. Abnormalities that can not be felt by the doctor may require an intraoperative ultrasound to localise them or a preoperative guide wire or localisation with carbon.
The procedure is performed under general anaesthetic and occasionally a guide wire is required in order to localise an imaging abnormality. A tiny wire which looks very similar to a fishing line can be placed in the breast preoperatively under ultrasound or mammographic vision. The wire will allow Dr Thornton to excise the correct area during the operation.
An open surgical excisional biopsy is usually performed as a day case.
If a wire is required to be placed preoperatively, the patient will attend the radiology department on the day of the procedure. A small amount of local anaesthetic will be inserted into the skin over the breast and the guide wire will be placed in the abnormal area. A mammogram will be performed in order to determine the exact location of the wire in the breast. The mammogram will be performed under minimal pressure so that external movement does not move the wire. Once the wire is shown to be in the correct position, it will be taped in place and the patient will then be transferred to the operating theatre. Most patients tolerate the procedure well with very minimal pain.
When an open surgical excisional biopsy is performed it is important that particular care and attention are paid to the site where the incision will be placed. Preoperatively Dr Thornton will discuss in detail with the patient the site of the surgical incision. The aim is to achieve the best possible cosmetic result while ensuring the lump or imaging abnormality is removed safely and successfully.
In the operating theatre, the patient will meet with the anaesthetist and will be placed under general anaesthetic. Dr Thornton will remove the lump or the tissue containing the wire with the imaging abnormality. The specimen with the wire in place will be sent to the x-ray department for an x-ray to confirm that the abnormal area with the hookwire has been removed.
If the patient has a palpable lump ( a lump that the doctor can feel ) a hook wire will not be required. Occasionally impalpable lumps will not require placement of a hookwire and an ultrasound machine can be used in the operating theatre to help localise the abnormality.
Particular care will be paid to opposing the breast tissue in the correct surgical planes and closing the skin with plastic surgical style absorbable sutures. This is to ensure that the best cosmetic result is achieved. A small waterproof dressing will be applied.
Dr Thornton will usually meet with patients who have undergone an excisional biopsy within the next 48 hours in order to discuss the operative pathology.
Complications of Excisional Biopsies:
Postoperative Pain: Most women will not have significant pain postoperatively. Paracetamol is recommended strictly and regular for 72 hours after the operation.
Infection of the wound occurs in a very small percentage of cases, up to approximately 4% and is usually well treated with oral antibiotics.
Bruising, bleeding, and haematomas are quite common after breast surgery and usually do not require return to theatre. However, occasionally a return to theatre to evacuate a haematoma is required. The patient should be aware of sudden swelling in the breast which may indicate bleeding requiring further surgery.
Scarring and changes to the size and shape of the breast can also occur. Hypertrophic or keloid scarring tend to be more common in patients with highly pigmented skin. Consideration is always given to placement of the scar and at all costs every attempt should be made to ensure that scars are not placed in the décolletage. The best scars usually heal where the incision is made around the areola.
There can occasionally be a need for further surgery particularly if cancer cells are found unexpectedly at operation.
There are also rare problems with insertion of the guide wire itself and this can occasionally cause some discomfort and bruising to the breast. Sometimes, more than 1 wire is required to be placed and this may make patients feel faint. There is a nurse accompanying the patient at all times. An extremely rare side effect of guide wire insertion is collapse of the lung (pneumothorax).
In some cases whena hookwire is placed, the abnormality will not be found in the tissue that is retrieved. There are several reasons why this can occur - in particular, the hookwire may move in the breast during the transit of the patient from the radiology department to the operating suite. There are also other technical reasons why this can occur. This problem would usually require a return to theatre at a later date and a re-localisation of the abnormality with a wire.
Some patients will feel tired and will have some postoperative nausea and vomiting after general anaesthetic. Allergic reactions to anaesthetic drugs are very uncommon.
