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Breast Biopsy: The Two-Stage Procedure and Fine-Needle Aspiration

With the advent of lumpectomy, there was a need to adopt a two-stage approach to

biopsy and then to definitive surgery. One difficulty with this approach was the frequent

failure to obtain pathologically clear margins, especially if the surgeon's intent was biopsy

and not excision. This created the need for a second procedure in a recently operated site withthe likelihood of difficulties in orientation. The wide acceptance of preoperative core needle

biopsies, either clinically or radiologically directed, has solved this problem. This approach

should be considered standard, so that the surgeon has a definite diagnosis before any surgery

takes place and can better plan the operation. A detailed algorithm describing an optimal

surgical strategy for the management of primary breast cancer has been described and is

presented in Figure 121-25.83

If an open breast biopsy must be carried out it should be done as if a lumpectomy

were being performed. Attention must be given to ensuring that specimen margins are likely

to be free of tumor should a malignancy be encountered. Today, it is inappropriate to perform

a biopsy without paying attention to specimen margins. In all circumstances where breast

conservation is feasible, the operation carried out to establish the definitive diagnosis of a

breast lesion becomes the definitive treatment whether axillary surgery is done at that time or

later. Recent experience has shown that most breast cancer operationsbiopsy, lumpectomy,

axillary dissection, and even mastectomycan be performed as out-patient procedures with

comparable low levels of surgical complications and equal or better personal and social

adjustment to the procedure.

The use of fine-needle aspiration to establish the diagnosis of a breast lesion is now a

standard approach, particularly for patients with clinical and/or mammographic lesions that

are highly suspicious for being cancer. In Sweden, fine-needle aspiration has been theprocedure of choice at the Karolinska Institute for more than 30 years. The Institute's rate of

false-negative cytologic reports is less than 10%; false-positive diagnosis almost never

occurs.89The experience is best exemplified by the report of Wallgren and colleagues, who

noted that, in a trial to evaluate preoperative radiation, the diagnosis was established by fine-

needle aspiration in 960 women and that patients received preoperative radiation based on

this diagnosis.90 An increasing number of reports in the American literature also describe the

use of fine-needle aspiration. In a recent review, Hammond et al. describe experience with

4,943 aspirations from seven major institutions; other findings indicate that there are only a

few anecdotal reports of false-positive aspirations.66, 9193 The incidence of false positives is

rare, far below 1%, and probably approximates the incidence of false-positive diagnoses of

breast tumors by tissue examination. There is general agreement that success with this

technique relates to the cumulative experience of the individual carrying out the aspiration

and the pathologist interpreting the material he or she receives. The preparation of the smear

is also of major importance. Core needle biopsy is in many ways simpler and provides more

exact diagnoses, especially in distinguishing invasive from noninvasive cancers.

http://www.ncbi.nlm.nih.gov/books/NBK13297/figure/A30911/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31526http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31532http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31532http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31533http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31509http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31534http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31526http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31532http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31533http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31509http://www.ncbi.nlm.nih.gov/books/n/cmed6/A31066/#A31534http://www.ncbi.nlm.nih.gov/books/NBK13297/figure/A30911/?report=objectonly

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Algoritma Penatalaksanaan Karsinoma Mammae

Recommended surgical strategy for management of primary breast cancer.