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The excisional breast biopsy (EBB) is defined as a surgical procedure in which an indeterminate lesion or calcifications are removed from the breast. In addition to establishing a tissue diagnosis, the secondary goal is complete removal of the lesion or calcifications in question.

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The traditional method of obtaining a tissue diagnosis of a palpable breast mass is the EBB. If the practitioner feels a suspicious mass, then the next appropriate step is to obtain diagnostic imaging in the form of a bilateral mammogram and a unilateral ultrasound directed at the suspicious lesion. The ultrasound will distinguish a simple cyst from a complex cyst or solid mass in addition to further characterization of any solid lesion. The bilateral mammogram will effectively screen the contralateral breast and provide comparison in the parenchymal tissue pattern between both breasts.

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If the imaging is noncontributory but the practitioner is still concerned about the palpable mass, the option of fine-needle aspiration, percutaneous core biopsy (PCB), or an EBB should be considered. At any time, the patient may opt for EBB rather than observation or PCB.

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If an indeterminate solid lesion or calcifications are identified by mammogram or ultrasound, an image-guided PCB is the preferred approach for tissue diagnosis. If the practitioner cannot perform an image-guided PCB personally or does not have a local radiologist who can perform a PCB, then image-guided localization and EBB are indicated.

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A radial scar has a very distinct mammographic pattern, characterized by a spiculated density, often with a radiolucent center. An EBB is usually the most efficient means of making the diagnosis of radial scar because a benign result obtained by PCB would be considered discordant with the suspicious imaging characteristics, and an EBB would ultimately be recommended. In addition, occult malignancy has been reported in 4% of patients diagnosed with radial scar by PCB who subsequently underwent EBB.1 A patient who presents with pathologic nipple discharge and has a retroareolar lesion seen by mammogram, ultrasound, or ductogram should also undergo an EBB because the lesion often represents a papillary lesion. The diagnosis of a papillary lesion on PCB should prompt an EBB for definitive diagnosis to rule out a papillary carcinoma, and therefore PCB is often not helpful in establishing a benign diagnosis.

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Once a PCB has been performed (either directed by palpation or image-guided), the tissue diagnosis may prompt an EBB. EBB is indicated if the PCB results reveal lobular carcinoma in situ (particularly if the lobular carcinoma in situ is associated with necrosis or calcifications), atypical ductal hyperplasia, atypical lobular hyperplasia, columnar cell lesion with atypia, radial scar, or a papillary lesion. The concern regarding these diagnoses obtained by PCB is that an error in sampling by the radiologist or an error in interpretation by the pathologist may have occurred, which can produce a false-negative diagnosis. The diagnosis of columnar cell lesion with atypia is concerning because of the ...

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