Out-patient Breast Biopsies R. ROBINSON BAKER, M.D.
From the Departments of Surgery and Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Because an increasing number of women do not wish to be anesthetized not knowing the specific diagnosis and not knowing if they will awaken with or without their breast, the traditional approach of biopsy under general anesthesia, frozen section and simultaneous mastectomy has been abandoned in most instances. One-hundred and fifty-three consecutive biopsies have been performed under local anesthesia. Nineteen patients proved to have a carcinoma, 23 patients had non-obligate precursors of carcinoma, five patients had a lymphoma and the remaining patients had benign disease. No significant complications occurred. Breast biopsies under local anesthesia avoid a good deal of psychologic trauma to the patient and allow the surgeon to plan therapy based on a precise histologic diagnosis. There are also substantial savings on both the direct and indirect cost of a breast biopsy under local anesthesia compared to a similar procedure under general anesthesia.
from the cyst on aspiration, these patients were also excluded from the study. One-hundred and nineteen patients undergoing biopsy under local anesthesia had a clinically benign, discrete mass which did not contain fluid on needle aspiration. Twenty patients with indiscrete masses which were suspicious of malignancy on clinical examination were also included as were five patients under treatment for lymphoma who developed discrete masses in their breast during the course of therapy. Although an appreciable number of patients had mammograms or xeroradiograms prior to referral, I did not employ either of these procedures as a means of determining the etiology of the palpable mass. Nine women with clinically obvious cancer were advised to have a biopsy under general anesthesia and to undergo a simultaneous mastectomy if a diagnosis of cancer was established by frozen section. These women preferred to have the diagnosis established by biopsy under local anesthesia and were included in the group of patients under discussion.
ALTHOUGH THE SURGICAL treatment of breast cancer < remains controversial, all authorities agree that treatment can only be instituted after a histologic diagnosis of cancer has been established. The traditional clinical approach has been to perform either an incisional or excisional biopsy under general anesthesia and proceed with a mastectomy if a diagnosis of cancer was established by microscopic examination of a frozen section of the biopsy specimen. Because an increasing number of women do not wish to be anesthestized not knowing the specific diagnosis and not knowing if they will awaken with or without their breast, the traditional approach of biopsy under general anesthesia, frozen section and simultaneous mastectomy was abandoned several years ago. A clinical study designed to evaluate breast biopsies under local anesthesia was initiated. This paper describes the results in the first 153 consecutive patients. Patient Selection The patients ranged in age from 18 to 77, their mean age was 45. Those patients with xeroradiographic or mammographic evidence of a breast lesion but no palpable disease were excluded from this study. If a cyst was suspected clinically and fluid could be obtained Presented at the Annual Meeting of the Southern Surgical Association, December 5-8, 1976, Palm Beach, Florida. Submitted for publication: December 10, 1976.
Technique All procedures were performed in the general operating room with one assistant. No pre-medication was employed and no patient received intravenous fluids. The anesthetic mixture consisted of 50 cc of 1% lidocaine (xylocaine) containing 0.5 mg of epinephrine. Usually only 20 to 30 ml of this solution were used to produce a field of block. In order to avoid inadvertent injection into a blood vessel, the syringe was always aspirated prior to the injection of the local anesthetic. An effort was made to avoid injecting the local anesthetic directly into a tumor mass or to inject the local anesthetic beneath the pectoral fascia. Circumareolar incisions were performed whenever possible. If a circumareolar incision was not feasible, circumferential incisions within skin lines were performed. After the skin incision, most of the remaining dissection was performed with the cautery, employing
543
BAKER
544 TABLE 1. Histologic Diagnoses in 153 Breast Biopsies
Histologic Diagnoses
Number of Cases
0/0
Carcinoma Lobular hyperplasia Papillomatosis Fibroadenoma Fibrocystic disease Lymphoma Miscellaneous No histologic abnormality
19 4 19 27 71 5 5 3
13 2 13 17 46 3 3 2
the coagulation current for hemostasis and the cutting current for excision of the lesion. In the majority of cases, the palpable mass was totally excised. Large indiscrete masses were partially excised for histologic study. Cystic lesions were partially excised with a fragment of surrounding breast tissue and the remainder of the cyst wall was destroyed with the cautery. The defect in the breast tissue was closed with wide sutures of 2-0 dexon. The skin was closed with either a pull-out suture of 4-0 nylon or a subcuticular suture of 5-0 dexon. Drains were never employed. The patients were instructed to wear a tight brassiere for 48 hours following the operation. If the biopsy specimen was grossly suspicious of malignancy, a frozen section was obtained. Those patients who proved to have malignant tumors were admitted to the hospital within one to three days of the biopsy for further diagnostic studies. Definitive treatment was carried out within four days of the histologic diagnosis.
Complications None of the patients required hospitalization for any type of complication resulting from the biopsy procedure. One patient developed a small hematoma which healed without complication after 4 cc of clotted blood were removed by needle aspiration. Ten percent of the patients developed small focal areas of second degree skin loss along the skin edges. These lesions which were attributed to the epinephrine in the local anesthetic mixture, healed without further treatment in all instances. There were no wound infections. Results The operations produced very little anxiety in the majority of patients. It was never necessary to discontinue the procedure because of apprehension or pain. Only a few patients complained of any significant pain in the postoperative period. The majority of the patients required nothing stronger than aspirin for postoperative pain. The various types of histologic diagnoses established in the 153 cases are reviewed in Table 1. Nineteen
Ann. Surg. * May 1977
patients (12%) proved to have a malignant tumor. These patients ranged in age from 35 to 77, the median age was 52. Ten of these patients were thought to have benign disease preoperatively. In four of these ten patients, a preoperative xeroradiogram had revealed no evidence of malignancy. As previously noted, the remaining nine patients had a clinical diagnosis of carcinoma. Sixteen of the 19 patients with a diagnosis of carcinoma have remained free of disease after primary therapy (median follow-up 27 months). One patient died of congestive heart failure 14 months after a quadrant excision of the primary tumor. She had no evidence of recurrence. Another patient had evidence of lumbar spine metastases on a bone scan which was obtained following the biopsy procedure. This patient has remained free of further systemic disease 24 months following irradiation of the spine and the excisional biopsy. There is no evidenc of residual disease in the breast either by physical examination or xeroradiography. The remaining patient developed evidence of systemic metastases 20 months after a radical mastectomy and internal mammary node dissection for carcinoma in the medial quadrants of the right breast. The remaining 134 patients had a variety of histologic diagnoses. Twenty-three patients had papillomatosis and/or lobular hyperplasia, both of these lesions are considered to be non-obligate precursors of breast cancer.3 Ninety-eight patients had either fibroadenomata or histologic evidence of fibrocystic disease other than papillomatosis or lobular hyperplasia. All five patients under treatment for a lymphoma proved to have lymphomas rather than a primary breast cancer. Two patients had a lipoma and three patients had inflammatory lesions of the breast. In three instances, no histologic abnormality was found to account for the preoperative physical finding. The apparent mass detected preoperatively proved to be either a nodule of breast tissue or fat. No discrete mass was palpable in any of these three patients postoperatively. Discussion
This series demonstrates that breast biopsies can be performed on an out-patient basis under local anesthesia without significant complication. Similar results have been reported by Abramson,1 Caffee,2 Hunt,5 Mullen7 and Saltzstein.9 In Abramson's1 and Hunt's5 series, patients over 40 years of age or those patients with any clinical suspicion of malignancy were excluded from the group of patients undergoing breast biopsy under local anesthesia. I see no reason to exclude such patients. As previously noted, biopsy under local anesthesia has been offered to any patient with a breast mass regardless of age. Although patients with
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OUT-PATIENT BREAST BIOPSIES
clinical evidence of malignancy were advised to have the biopsy performed under general anesthesia with an immediate mastectomy if the frozen section was positive, those patients who did not elect this particular type of management were biopsied under local anesthesia. In contrast to Abramson, Hunt and Mullen, my experience has demonstrated no need for any type of pre-medication in the great majority of patients. There are many advantages to breast biopsies under local anesthesia particularly in regard to the psychological trauma associated with the management of a breast mass. Women with a breast mass are confronted with two problems: 1) the etiology of the mass; and 2) the possibility of losing their breast. Both of these situations produce a high level of anxiety and frequently result in a delay in diagnosis. An increasing number of women will consent to biopsy under local anesthesia because they know that nothing further will be done until a histologic diagnosis is established. Breast biopsies under local anesthesia also avoid the psychologic trauma of an unsuspected mastectomy and allows the patient to prepare herself for mastectomy. Increased patient acceptance and the lack of any significant morbidity allows the surgeon to determine a histologic diagnosis in any patient with a breast mass which does not contain fluid and also in any patient with an indiscrete mass which is even slightly suspicious of malignancy on physical examination. Ten patients in this series with apparent benign tumors proved to have malignant tumors on biopsy. Pre-treatment biopsy also allows the surgeon to plan appropriate therapy based on a precise histologic diagnosis rather than a diagnosis of "cancer" reported on the frozen section. Histologic type and histologic grade of the tumor can be established and this information can be utilized in discussing further therapy with the patient. Breast biopsies provide the pathologist with an opportunity to examine the breast tissue adjacent to the palpable mass. In a small but significant number of cases, obligate precursors of breast cancer such as lobular carcinoma in situ or intraductal carcinoma are discovered. These non-palpable lesions are, of course, only discovered by chance. Although no such lesions were found in this series, 23 patients did prove to have non-obligate precursors of breast cancer such as papillomatosis and lobular hyperplasia. There are a number of practical benefits to breast biopsies under local anesthesia. The savings in direct cost are substantial. In this Institution there is a $500 differential in cost between biopsies under local anesthesia and hospitalization with biopsy under general anesthesia. There are also significant indirect savings. Only those patients with histologic evidence of malignancy are scheduled for operation. The practice of
545
scheduling a patient for a breast biopsy, frozen section and possibly mastectomy is avoided and valuable operating room time is not wasted. There is also a saving in the cost of operating the blood bank since only those patients with definite diagnosis of cancer are cross-matched for possible blood transfusions. Several authorities are opposed to breast biopsy under local anesthesia. Haagenson4 is opposed because he feels that breast biopsies under local anesthesia are apt to be done with poor surgical technique and with less than adequate pre-treatment evaluation. He also feels that the patient might not realize the seriousness of the lesion in her breast. None of these objections appear to be valid, particularly as they relate to pretreatment evaluation. Breast biopsies under local anesthesia, if anything, increase the accuracy of pre-treatment evaluation since they result in a precise histologic diagnosis. Urban" is opposed to preoperative biopsies on the basis that any delay in treatment may jeopardize the patient's chance of ultimate survival but only apparently if the delay is greater than two weeks between biopsy and definitive therapy. Scheel,10 Jackson6 and Haagenson4 have all published studies which demonstrate no adverse effect of a delay of several days between biopsy and definitive therapy. In this series of cases, there was no significant delay between diagnosis and definitive therapy. Biopsy under local anesthesia followed by a subsequent mastectomy also appeared to have no effect on the incidence of local or systemic recurrence in this small series of cases. Urban's" other objection, a tendency to limit the extent of the biopsy if the procedure is done under local anesthesia, is a legitimate one and an effort should be made to excise not only the palpable mass but also a generous fragment of adjacent breast tissue. Reactions to lidocaine are another possible objection to breast biopsies under local anesthesia. Two general types of reactions to lidocaine occur, either a hypersensitivity reaction or central nervous system or cardiovascular reactions secondary to high plasma levels of the drug. Although hypersensitivity reactions to lidocaine are quite rare, specific inquiries into a history of hypersensitivity reaction should be made prior to operation. Central nervous system reactions and/or cardiovascular reactions to lidocaine are secondary to the inadvertent injection of the local anesthetic; avoiding intravascular injections, can obviate these central nervous system and/or cardiovascular reactions. Perhaps the most serious objection to breast biopsies under local anesthesia is the possibility of introducing cancer cells into either the lymphatic or venous circulations with the needle used to inject the local anesthetic. I believe this is more of a theoretical than practical
BAKER
546
consideration and there has been no clinical evidence either in this series or any other series to indicate that patients subjected to breast biopsies under local anesthesia have a higher incidence of systemic metastases. An alternate method to breast biopsy under local anesthesia is the use of needle aspiration of a breast mass and the cytologic and/or histologic examination of the needle biopsy specimens. I have had no experience with this technique except for aspiration of suspected cysts. In a large series of cases, Rimsten8 reports no false positive cases and a remarkably low incidence of false negatives. This technique, therefore, appears to warrant further investigation.
3. 4. 5.
6. 7.
8.
9.
References 10. 1. Abramson, D. J.: 857 Breast Biopsies as an Out-patient Procedure; Delayed Mastectomy in 41 Cases. Ann. Surg., 163: 478, 1966. 2. Caffee, H. H. and Benfield, J. R.: Data Favoring Biopsy of the
DiSCUSSION
DR. RICHARD J. FIELD, JR. (Centreville, Mississippi): At our institution, we have felt for many years that out-patient breast biopsies allow adequate psychological and emotional preparation for the super-anxious female facing the possibility of carcinoma of the breast. In contrast to this attitude is that of placing the patient under general anesthesia and possibly doing an immediate mastectomy. (Slide) We have a few deviations from your routine. If you all will indulge this printing of mine, I have jotted it down. We bring them in the morning of surgery. We do admit them. We do a biopsy under local anesthesia, and also give preoperative medication. We even give a little Valium intravenously, if they are really apprensive about the whole procedure. We do a frozen section, and await its results. If the section is benign, we discharge the patient that same day. However, if it is malignant, we sit down and discuss the problem at length with the family. It has been our belief for a long time that the Golden Rule is the most effective approach. It is my opinion that if this were I, I would like to have someone sit down and talk to me about what is going to happen to my breast, assuming it has carcinoma in it. The patients appreciate this approach, and I think that, as a result, they do better postoperatively. We then prepare the patient that afternoon and do a radical mastectomy the following morning. I am grateful to Dr. Baker for surfacing this problem that I think has been overlooked for many years. I think this approach that he has described is a better way. (Slide) We reviewed the last 130 of these that we have done under local anesthesia. Nineteen of ours were carcinomas, for a 15% incidence of carcinoma in these that we have done under local anesthesia. DR. JAMES F. NEWSOME (Chapel Hill, North Carolina): I would agree thoroughly with the humanistic concerns he has expressed; but there are other reasons, some of which have already been mentioned. As Dr. Baker has indicated, if one knows the nature of a mass, he can more intelligently decide the treatment necessary. Some years ago, because of a lack of beds and a crowded operating schedule, we began breast biopsies as an out-patient procedure. We're just not reviewing our experience of the last two years, which is in excess of 200 patients. Our approach differs from Dr. Baker's and, indeed, from that just mentioned by Dr. Field. We use a needle as a preliminary testing
11.
Ann. Surg. . May
1977
Breast under Local Anesthesia. Surg. Gynecol. Obstet., 140: 88, 1975. Carter, D.: Intraductal Papillary Tumors of the Breast: A Study of 78 Cases. Cancer, in press. Haagenson, C. D., ed.: Diseases of the Breast, W. B. Saunders, 1971. Hunt, T. K. and Crass, R. A.: Breast Biopsies on Out-Patients. Surg. Gynecol. Obstet., 141:591, 1975. Jackson, P. P. and Pitts, H. H.: Biopsy with Delayed Radical Mastectomy for Carcinoma of the Breast. Am. J. Surg., 98: 184, 1959. Mullen, J. T., Biesecker, G. L. and Knapp, R. W.: Patient Acceptance of Local Anesthesia for Breast Biopsy. Am. Surg., 42:355, 1976. Rimsten, A., Stenkvist, B., Johanson, H. and Lindgren, A.: The Diagnostic Accuracy of Palpation and Fine-Needle Biopsy and an Evaluation of Their Combined Use in the Diagnosis of Breast Lesions. Ann. Surg., 182:1, 1975. Saltzstein, E. C., Mann, R. W., Chua, T. Y. and DeCosse, J. J.: Out-Patient Breast Biopsy. Surg. Gynecol. Obstet., 109: 287, 1974. Scheel, A.: The Risk of Excisional Biopsy of Cancer of the Breast. Transactions of The Northern Surgical Association, Twenty-fifth Meeting, Copenhagen, Ejnar Munksgaard, 1951. Urban, J. A.: The Case Against Delayed Operation for Breast Cancer. CA, 21:132, 1971.
procedure. I'm impressed with the frequency with which the presence of cancer can be confirmed by cytologic study of saline washings of a 19-gauge needle and syringe, when no fluid is recovered. If a firm diagnosis cannot be made in this manner, then biopsy is carried out in the out-patient department under local anesthesia. (Slide) Rarely do we use more than 10 cc of Xylocaine. Adrenalin is never used. (Slide) (Slide) I never use the electric cautery. The wound is managed as shown here. (Slide) This happens to be a biopsy for nipple discharge from an intraductal papilloma demonstrated by ductogram. (Slide) And here one can see the area which has been exposed, with the intraductal papilloma at this point. (Slide) And wound closure with sterile tape. (Slide) And here's the specimen, indicating that one can, indeed, excise an adequate margin of tissue quite readily, anesthetizing the skin only. (Slide) Now, one has the opportunity, at least in our institution, of doing such procedures in one of three ways: In the minor operating room of the out-patient department under local, as I have demonstrated here; in the so-called "day-op" program, where the patient is admitted to the hospital in the morning, and under local, or with general anesthesia, the biopsy is procured, and then she is discharged; or, indeed, in the more traditional method of admitting the patient to the hospital for a biopsy and frozen section under general anesthesia in a general operating suite. I'd like to point out to you that if on cytologic study one can establish a diagnosis, basic charges are about $60. In some instances, one does have to proceed with a biopsy, and here I have listed basic charges for each method. In the minor operating room, charges are less than $300; in the "day-op" program, something less than $500; and in the general hospital setting, something over $700. The savings here are quite evident. Not included in this, of course, but also important are the savings in time and money in permitting the operating room to be more appropriately used. I would agree entirely with Dr. Baker that the objections raised by several authors, I believe, are more imagined than real. An adequate margin can be procured. There is no documented instance of reaction to lidocaine, at least in our series. And introduction of malignant cells into the bloodstream should be of no more concern than with any other method, in that it's not necessary to infiltrate the breast tissue at all. The average time required for biopsy in the patients that we have studied is less than 40 minutes. And lastly, as I have already indicated, I would view the needle aspiration not as an alternate method, but as an adjunct to the diagnosis of a breast lesion. And I would emphasize one other point. If one is to rely upon needle aspiration, you must have a superb cytologist.
From the Departments of Surgery and Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Because an increasing number of women do not wish to be anesthetized not knowing the specific diagnosis and not knowing if they will awaken with or without their breast, the traditional approach of biopsy under general anesthesia, frozen section and simultaneous mastectomy has been abandoned in most instances. One-hundred and fifty-three consecutive biopsies have been performed under local anesthesia. Nineteen patients proved to have a carcinoma, 23 patients had non-obligate precursors of carcinoma, five patients had a lymphoma and the remaining patients had benign disease. No significant complications occurred. Breast biopsies under local anesthesia avoid a good deal of psychologic trauma to the patient and allow the surgeon to plan therapy based on a precise histologic diagnosis. There are also substantial savings on both the direct and indirect cost of a breast biopsy under local anesthesia compared to a similar procedure under general anesthesia.
from the cyst on aspiration, these patients were also excluded from the study. One-hundred and nineteen patients undergoing biopsy under local anesthesia had a clinically benign, discrete mass which did not contain fluid on needle aspiration. Twenty patients with indiscrete masses which were suspicious of malignancy on clinical examination were also included as were five patients under treatment for lymphoma who developed discrete masses in their breast during the course of therapy. Although an appreciable number of patients had mammograms or xeroradiograms prior to referral, I did not employ either of these procedures as a means of determining the etiology of the palpable mass. Nine women with clinically obvious cancer were advised to have a biopsy under general anesthesia and to undergo a simultaneous mastectomy if a diagnosis of cancer was established by frozen section. These women preferred to have the diagnosis established by biopsy under local anesthesia and were included in the group of patients under discussion.
ALTHOUGH THE SURGICAL treatment of breast cancer < remains controversial, all authorities agree that treatment can only be instituted after a histologic diagnosis of cancer has been established. The traditional clinical approach has been to perform either an incisional or excisional biopsy under general anesthesia and proceed with a mastectomy if a diagnosis of cancer was established by microscopic examination of a frozen section of the biopsy specimen. Because an increasing number of women do not wish to be anesthestized not knowing the specific diagnosis and not knowing if they will awaken with or without their breast, the traditional approach of biopsy under general anesthesia, frozen section and simultaneous mastectomy was abandoned several years ago. A clinical study designed to evaluate breast biopsies under local anesthesia was initiated. This paper describes the results in the first 153 consecutive patients. Patient Selection The patients ranged in age from 18 to 77, their mean age was 45. Those patients with xeroradiographic or mammographic evidence of a breast lesion but no palpable disease were excluded from this study. If a cyst was suspected clinically and fluid could be obtained Presented at the Annual Meeting of the Southern Surgical Association, December 5-8, 1976, Palm Beach, Florida. Submitted for publication: December 10, 1976.
Technique All procedures were performed in the general operating room with one assistant. No pre-medication was employed and no patient received intravenous fluids. The anesthetic mixture consisted of 50 cc of 1% lidocaine (xylocaine) containing 0.5 mg of epinephrine. Usually only 20 to 30 ml of this solution were used to produce a field of block. In order to avoid inadvertent injection into a blood vessel, the syringe was always aspirated prior to the injection of the local anesthetic. An effort was made to avoid injecting the local anesthetic directly into a tumor mass or to inject the local anesthetic beneath the pectoral fascia. Circumareolar incisions were performed whenever possible. If a circumareolar incision was not feasible, circumferential incisions within skin lines were performed. After the skin incision, most of the remaining dissection was performed with the cautery, employing
543
BAKER
544 TABLE 1. Histologic Diagnoses in 153 Breast Biopsies
Histologic Diagnoses
Number of Cases
0/0
Carcinoma Lobular hyperplasia Papillomatosis Fibroadenoma Fibrocystic disease Lymphoma Miscellaneous No histologic abnormality
19 4 19 27 71 5 5 3
13 2 13 17 46 3 3 2
the coagulation current for hemostasis and the cutting current for excision of the lesion. In the majority of cases, the palpable mass was totally excised. Large indiscrete masses were partially excised for histologic study. Cystic lesions were partially excised with a fragment of surrounding breast tissue and the remainder of the cyst wall was destroyed with the cautery. The defect in the breast tissue was closed with wide sutures of 2-0 dexon. The skin was closed with either a pull-out suture of 4-0 nylon or a subcuticular suture of 5-0 dexon. Drains were never employed. The patients were instructed to wear a tight brassiere for 48 hours following the operation. If the biopsy specimen was grossly suspicious of malignancy, a frozen section was obtained. Those patients who proved to have malignant tumors were admitted to the hospital within one to three days of the biopsy for further diagnostic studies. Definitive treatment was carried out within four days of the histologic diagnosis.
Complications None of the patients required hospitalization for any type of complication resulting from the biopsy procedure. One patient developed a small hematoma which healed without complication after 4 cc of clotted blood were removed by needle aspiration. Ten percent of the patients developed small focal areas of second degree skin loss along the skin edges. These lesions which were attributed to the epinephrine in the local anesthetic mixture, healed without further treatment in all instances. There were no wound infections. Results The operations produced very little anxiety in the majority of patients. It was never necessary to discontinue the procedure because of apprehension or pain. Only a few patients complained of any significant pain in the postoperative period. The majority of the patients required nothing stronger than aspirin for postoperative pain. The various types of histologic diagnoses established in the 153 cases are reviewed in Table 1. Nineteen
Ann. Surg. * May 1977
patients (12%) proved to have a malignant tumor. These patients ranged in age from 35 to 77, the median age was 52. Ten of these patients were thought to have benign disease preoperatively. In four of these ten patients, a preoperative xeroradiogram had revealed no evidence of malignancy. As previously noted, the remaining nine patients had a clinical diagnosis of carcinoma. Sixteen of the 19 patients with a diagnosis of carcinoma have remained free of disease after primary therapy (median follow-up 27 months). One patient died of congestive heart failure 14 months after a quadrant excision of the primary tumor. She had no evidence of recurrence. Another patient had evidence of lumbar spine metastases on a bone scan which was obtained following the biopsy procedure. This patient has remained free of further systemic disease 24 months following irradiation of the spine and the excisional biopsy. There is no evidenc of residual disease in the breast either by physical examination or xeroradiography. The remaining patient developed evidence of systemic metastases 20 months after a radical mastectomy and internal mammary node dissection for carcinoma in the medial quadrants of the right breast. The remaining 134 patients had a variety of histologic diagnoses. Twenty-three patients had papillomatosis and/or lobular hyperplasia, both of these lesions are considered to be non-obligate precursors of breast cancer.3 Ninety-eight patients had either fibroadenomata or histologic evidence of fibrocystic disease other than papillomatosis or lobular hyperplasia. All five patients under treatment for a lymphoma proved to have lymphomas rather than a primary breast cancer. Two patients had a lipoma and three patients had inflammatory lesions of the breast. In three instances, no histologic abnormality was found to account for the preoperative physical finding. The apparent mass detected preoperatively proved to be either a nodule of breast tissue or fat. No discrete mass was palpable in any of these three patients postoperatively. Discussion
This series demonstrates that breast biopsies can be performed on an out-patient basis under local anesthesia without significant complication. Similar results have been reported by Abramson,1 Caffee,2 Hunt,5 Mullen7 and Saltzstein.9 In Abramson's1 and Hunt's5 series, patients over 40 years of age or those patients with any clinical suspicion of malignancy were excluded from the group of patients undergoing breast biopsy under local anesthesia. I see no reason to exclude such patients. As previously noted, biopsy under local anesthesia has been offered to any patient with a breast mass regardless of age. Although patients with
Vol. 185 . No. S
OUT-PATIENT BREAST BIOPSIES
clinical evidence of malignancy were advised to have the biopsy performed under general anesthesia with an immediate mastectomy if the frozen section was positive, those patients who did not elect this particular type of management were biopsied under local anesthesia. In contrast to Abramson, Hunt and Mullen, my experience has demonstrated no need for any type of pre-medication in the great majority of patients. There are many advantages to breast biopsies under local anesthesia particularly in regard to the psychological trauma associated with the management of a breast mass. Women with a breast mass are confronted with two problems: 1) the etiology of the mass; and 2) the possibility of losing their breast. Both of these situations produce a high level of anxiety and frequently result in a delay in diagnosis. An increasing number of women will consent to biopsy under local anesthesia because they know that nothing further will be done until a histologic diagnosis is established. Breast biopsies under local anesthesia also avoid the psychologic trauma of an unsuspected mastectomy and allows the patient to prepare herself for mastectomy. Increased patient acceptance and the lack of any significant morbidity allows the surgeon to determine a histologic diagnosis in any patient with a breast mass which does not contain fluid and also in any patient with an indiscrete mass which is even slightly suspicious of malignancy on physical examination. Ten patients in this series with apparent benign tumors proved to have malignant tumors on biopsy. Pre-treatment biopsy also allows the surgeon to plan appropriate therapy based on a precise histologic diagnosis rather than a diagnosis of "cancer" reported on the frozen section. Histologic type and histologic grade of the tumor can be established and this information can be utilized in discussing further therapy with the patient. Breast biopsies provide the pathologist with an opportunity to examine the breast tissue adjacent to the palpable mass. In a small but significant number of cases, obligate precursors of breast cancer such as lobular carcinoma in situ or intraductal carcinoma are discovered. These non-palpable lesions are, of course, only discovered by chance. Although no such lesions were found in this series, 23 patients did prove to have non-obligate precursors of breast cancer such as papillomatosis and lobular hyperplasia. There are a number of practical benefits to breast biopsies under local anesthesia. The savings in direct cost are substantial. In this Institution there is a $500 differential in cost between biopsies under local anesthesia and hospitalization with biopsy under general anesthesia. There are also significant indirect savings. Only those patients with histologic evidence of malignancy are scheduled for operation. The practice of
545
scheduling a patient for a breast biopsy, frozen section and possibly mastectomy is avoided and valuable operating room time is not wasted. There is also a saving in the cost of operating the blood bank since only those patients with definite diagnosis of cancer are cross-matched for possible blood transfusions. Several authorities are opposed to breast biopsy under local anesthesia. Haagenson4 is opposed because he feels that breast biopsies under local anesthesia are apt to be done with poor surgical technique and with less than adequate pre-treatment evaluation. He also feels that the patient might not realize the seriousness of the lesion in her breast. None of these objections appear to be valid, particularly as they relate to pretreatment evaluation. Breast biopsies under local anesthesia, if anything, increase the accuracy of pre-treatment evaluation since they result in a precise histologic diagnosis. Urban" is opposed to preoperative biopsies on the basis that any delay in treatment may jeopardize the patient's chance of ultimate survival but only apparently if the delay is greater than two weeks between biopsy and definitive therapy. Scheel,10 Jackson6 and Haagenson4 have all published studies which demonstrate no adverse effect of a delay of several days between biopsy and definitive therapy. In this series of cases, there was no significant delay between diagnosis and definitive therapy. Biopsy under local anesthesia followed by a subsequent mastectomy also appeared to have no effect on the incidence of local or systemic recurrence in this small series of cases. Urban's" other objection, a tendency to limit the extent of the biopsy if the procedure is done under local anesthesia, is a legitimate one and an effort should be made to excise not only the palpable mass but also a generous fragment of adjacent breast tissue. Reactions to lidocaine are another possible objection to breast biopsies under local anesthesia. Two general types of reactions to lidocaine occur, either a hypersensitivity reaction or central nervous system or cardiovascular reactions secondary to high plasma levels of the drug. Although hypersensitivity reactions to lidocaine are quite rare, specific inquiries into a history of hypersensitivity reaction should be made prior to operation. Central nervous system reactions and/or cardiovascular reactions to lidocaine are secondary to the inadvertent injection of the local anesthetic; avoiding intravascular injections, can obviate these central nervous system and/or cardiovascular reactions. Perhaps the most serious objection to breast biopsies under local anesthesia is the possibility of introducing cancer cells into either the lymphatic or venous circulations with the needle used to inject the local anesthetic. I believe this is more of a theoretical than practical
BAKER
546
consideration and there has been no clinical evidence either in this series or any other series to indicate that patients subjected to breast biopsies under local anesthesia have a higher incidence of systemic metastases. An alternate method to breast biopsy under local anesthesia is the use of needle aspiration of a breast mass and the cytologic and/or histologic examination of the needle biopsy specimens. I have had no experience with this technique except for aspiration of suspected cysts. In a large series of cases, Rimsten8 reports no false positive cases and a remarkably low incidence of false negatives. This technique, therefore, appears to warrant further investigation.
3. 4. 5.
6. 7.
8.
9.
References 10. 1. Abramson, D. J.: 857 Breast Biopsies as an Out-patient Procedure; Delayed Mastectomy in 41 Cases. Ann. Surg., 163: 478, 1966. 2. Caffee, H. H. and Benfield, J. R.: Data Favoring Biopsy of the
DiSCUSSION
DR. RICHARD J. FIELD, JR. (Centreville, Mississippi): At our institution, we have felt for many years that out-patient breast biopsies allow adequate psychological and emotional preparation for the super-anxious female facing the possibility of carcinoma of the breast. In contrast to this attitude is that of placing the patient under general anesthesia and possibly doing an immediate mastectomy. (Slide) We have a few deviations from your routine. If you all will indulge this printing of mine, I have jotted it down. We bring them in the morning of surgery. We do admit them. We do a biopsy under local anesthesia, and also give preoperative medication. We even give a little Valium intravenously, if they are really apprensive about the whole procedure. We do a frozen section, and await its results. If the section is benign, we discharge the patient that same day. However, if it is malignant, we sit down and discuss the problem at length with the family. It has been our belief for a long time that the Golden Rule is the most effective approach. It is my opinion that if this were I, I would like to have someone sit down and talk to me about what is going to happen to my breast, assuming it has carcinoma in it. The patients appreciate this approach, and I think that, as a result, they do better postoperatively. We then prepare the patient that afternoon and do a radical mastectomy the following morning. I am grateful to Dr. Baker for surfacing this problem that I think has been overlooked for many years. I think this approach that he has described is a better way. (Slide) We reviewed the last 130 of these that we have done under local anesthesia. Nineteen of ours were carcinomas, for a 15% incidence of carcinoma in these that we have done under local anesthesia. DR. JAMES F. NEWSOME (Chapel Hill, North Carolina): I would agree thoroughly with the humanistic concerns he has expressed; but there are other reasons, some of which have already been mentioned. As Dr. Baker has indicated, if one knows the nature of a mass, he can more intelligently decide the treatment necessary. Some years ago, because of a lack of beds and a crowded operating schedule, we began breast biopsies as an out-patient procedure. We're just not reviewing our experience of the last two years, which is in excess of 200 patients. Our approach differs from Dr. Baker's and, indeed, from that just mentioned by Dr. Field. We use a needle as a preliminary testing
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Breast under Local Anesthesia. Surg. Gynecol. Obstet., 140: 88, 1975. Carter, D.: Intraductal Papillary Tumors of the Breast: A Study of 78 Cases. Cancer, in press. Haagenson, C. D., ed.: Diseases of the Breast, W. B. Saunders, 1971. Hunt, T. K. and Crass, R. A.: Breast Biopsies on Out-Patients. Surg. Gynecol. Obstet., 141:591, 1975. Jackson, P. P. and Pitts, H. H.: Biopsy with Delayed Radical Mastectomy for Carcinoma of the Breast. Am. J. Surg., 98: 184, 1959. Mullen, J. T., Biesecker, G. L. and Knapp, R. W.: Patient Acceptance of Local Anesthesia for Breast Biopsy. Am. Surg., 42:355, 1976. Rimsten, A., Stenkvist, B., Johanson, H. and Lindgren, A.: The Diagnostic Accuracy of Palpation and Fine-Needle Biopsy and an Evaluation of Their Combined Use in the Diagnosis of Breast Lesions. Ann. Surg., 182:1, 1975. Saltzstein, E. C., Mann, R. W., Chua, T. Y. and DeCosse, J. J.: Out-Patient Breast Biopsy. Surg. Gynecol. Obstet., 109: 287, 1974. Scheel, A.: The Risk of Excisional Biopsy of Cancer of the Breast. Transactions of The Northern Surgical Association, Twenty-fifth Meeting, Copenhagen, Ejnar Munksgaard, 1951. Urban, J. A.: The Case Against Delayed Operation for Breast Cancer. CA, 21:132, 1971.
procedure. I'm impressed with the frequency with which the presence of cancer can be confirmed by cytologic study of saline washings of a 19-gauge needle and syringe, when no fluid is recovered. If a firm diagnosis cannot be made in this manner, then biopsy is carried out in the out-patient department under local anesthesia. (Slide) Rarely do we use more than 10 cc of Xylocaine. Adrenalin is never used. (Slide) (Slide) I never use the electric cautery. The wound is managed as shown here. (Slide) This happens to be a biopsy for nipple discharge from an intraductal papilloma demonstrated by ductogram. (Slide) And here one can see the area which has been exposed, with the intraductal papilloma at this point. (Slide) And wound closure with sterile tape. (Slide) And here's the specimen, indicating that one can, indeed, excise an adequate margin of tissue quite readily, anesthetizing the skin only. (Slide) Now, one has the opportunity, at least in our institution, of doing such procedures in one of three ways: In the minor operating room of the out-patient department under local, as I have demonstrated here; in the so-called "day-op" program, where the patient is admitted to the hospital in the morning, and under local, or with general anesthesia, the biopsy is procured, and then she is discharged; or, indeed, in the more traditional method of admitting the patient to the hospital for a biopsy and frozen section under general anesthesia in a general operating suite. I'd like to point out to you that if on cytologic study one can establish a diagnosis, basic charges are about $60. In some instances, one does have to proceed with a biopsy, and here I have listed basic charges for each method. In the minor operating room, charges are less than $300; in the "day-op" program, something less than $500; and in the general hospital setting, something over $700. The savings here are quite evident. Not included in this, of course, but also important are the savings in time and money in permitting the operating room to be more appropriately used. I would agree entirely with Dr. Baker that the objections raised by several authors, I believe, are more imagined than real. An adequate margin can be procured. There is no documented instance of reaction to lidocaine, at least in our series. And introduction of malignant cells into the bloodstream should be of no more concern than with any other method, in that it's not necessary to infiltrate the breast tissue at all. The average time required for biopsy in the patients that we have studied is less than 40 minutes. And lastly, as I have already indicated, I would view the needle aspiration not as an alternate method, but as an adjunct to the diagnosis of a breast lesion. And I would emphasize one other point. If one is to rely upon needle aspiration, you must have a superb cytologist.
