Image-guided percutaneous biopsy is the technique of choice for the diagnosis of breast lesions. The transition from open to percutaneous techniques as the favored approach in this setting began in the mid-1990s and was complete by January 2005, at the time of the second international consensus conference on the diagnosis and management of image-detected breast cancer, organized by Silverstein.1
Percutaneous diagnosis is the optimal strategy for planning the management of malignant lesions. The open biopsy of the past has several disadvantages: (1) it usually requires an additional operating room procedure for breast cancer patients; (2) it yields unclear resection margins about twice as often as resection after percutaneous diagnosis; (3) it can complicate or even compromise oncoplastic surgical planning; and (4) it can eliminate options for neoadjuvant treatment.
With percutaneous diagnosis, both palpable and nonpalpable benign lesions may be left in place if the pathology results fully explain the imaged findings. For patients with benign breast biopsy results, representing approximately 80% of breast biopsies, the percutaneous route avoids the expense, distress, and morbidity of an open operation. For the informed patient who requests that a mass with benign features be removed, percutaneous excisional biopsy is ideal as well.
The vast majority of breast cancers and benign breast lesions can be diagnosed accurately with percutaneous large-core needle biopsy.2 Since the goal is diagnosis rather than therapy, surgeons performing image-guided biopsies usually leave most of the target lesion in place; any cancers found are later removed by lumpectomy. Percutaneous management of benign lesions (sampling or excisional biopsy) has several benefits. The patient is spared significant physical and emotional trauma as well as considerable cost. In addition, precious operating room time is reserved for the patients who need it most, enhancing the efficient use of hospital facilities and improving the care of those patients. It is important to note that the efficiency of percutaneous diagnosis can be nullified by the subsequent open surgical removal of a benign lesion already diagnosed by image-guided core biopsy. In retrospect, the surgeon, the patient, and her health insurance provider regret that the lesion was not removed with excisional biopsy (percutaneous or open) in the first place.
In certain circumstances it is critically important to proceed with open excision after image-guided percutaneous biopsy yields benign findings. The most common and the most important reason that benign lesions are removed after percutaneous core biopsy is a lack of concordance between breast imaging findings and the histopathology report. To avoid excision, the surgeon must be satisfied that the findings reported by the pathologist fully explain those on mammographic, sonographic, and physical examination. This rule should be followed without exception to avoid a false-negative result, since a missed diagnosis of breast cancer is unacceptable. In many cases, the experienced breast surgeon can weigh the pathologic findings in light of imaging results on mammography and sonography and determine whether they agree. Any doubt should spur ...