Surgical Approach

Preoperative mammography is essential prior to treatment of any patient with suspected malignancy. The mammogram may show the extent of the lesion, or additional lesions or microcalcification elsewhere in the breast that alter the operative approach. It may also show lesions in the other breast.

Preoperative cytology or histology must also be reviewed.

Technique of Breast Biopsy/Partial Mastectomy
The incision for breast biopsy or wide excision is placed to allow an adequate biopsy with a good cosmetic result, which does not compromise uture treatment (i.e., it fits within usual mastectomy flaps). Extensive tunneling is avoided. For central lesions, a periareolar incision is very satisfactory, but for peripheral lesions, the incision is placed close to the lesion in Langer's lines.

In the inferior part of the breast, a radial incision has been advocated (Fig. 7.1), although we have had better cosmetic success with the curved skin-line incision used elsewhere in the breast. To avoid tunneling when needle localization is used the incision is placed over the lesion, rather than close to the site of needle entry. If axillary dissection is required, a separate incision is used unless the lesion is located in the axillary tail.

Local anaesthetic is infiltrated prior to making the incision, and the skin and subcutaneous tissue are retracted (Fig. 7.2). The breast tissue overlying the mass is grasped with Allis clamps, and the mass is excised with sharp dissection (Fig. 7.3). Electrocautery is not used for the excision, as it makes pathologic assessment of the margins more difficult. The mass itself is not grasped with clamps, as this risks tumor disruption and dissemination.

The amount of tissue removed depends on the indication. A fibroadenoma is removed with little if any surrounding breast tissue. For a small suspicious lesion, it is wise to take a margin of about 1 cm so that the diagnostic excisional biopsy might also be adequate local surgery.

Diagnostic biopsy of an equivocal area should remove the lump if it is discrete, or consist of a representative sample if it is less well defined. For a breast cancer diagnosed on percutaneous biopsy, a 1cm margin of grossly normal breast tissue is removed. An ellipse of skin can be included with a superficial tumor.

The specimen should be oriented with clips or sutures to allow the pathologist to assess the margins. After needle-localized biopsy, specimen radiography is essential to ensure complete removal of the mammographic abnormality. If cancer is suspected, it is valuable to place titanium clips in the tumor bed to acilitate radiation targeting. In cases of inflammatory or locally advanced cancer, incisional biopsy may be needed for diagnosis and treatment planning.