MODERN OPERATIVE TECHNICS
Triage for the Breast Biopsy CAP1 Robert W. Knapp, MC USN, Portsmouth, Virginia CAP1 Joseph T. Mullen, MC USN, Portsmouth, Virginia
Local anesthesia has been used with relative infrequency in the United States to obtain histologic information on dominant breast masses. The approach to these lesions that has seemed most appropriate to American’ surgeons has been hospital admission and preparation for possible radical mastectomy. Biopsy under general anesthesia is performed, and cancers, if proved on frozen section, are usually treated surgically under the same anesthetic. During the past decade, investigators have questioned the “traditional” approach to breast biopsy and have proposed a greater use of local anesthesia for the initial operation [1,2]. Recent reports indicate a greater current interest in breast biopsy under local anesthesia than has been previously expressed [3,4]. In 1963, the Surgical Service at Naval Hospital, Naval Regional Medical Center (NRMC), Portsmouth, Virginia, abandoned the routine use of general anesthesia for breast biopsy. A method of management was developed that is based on two concepts. (1) Needle aspiration is attempted on threedimensional lesions. Any mass that does not yield fluid and disappear entirely is biopsied immediately. (2) Most biopsies are performed under local anesthesia on outpatients. Certain patients are selected for “standard” biopsy, under general anesthesia on the basis of high probability of malignancy or other reasons. Aspiration of Cysts. The useof needleaspiration to evacuate breast cysts has been advocated by some surgeons for years, but although most operators have used the method occasionally, few have adopted it as a routine [5,6]. Opponents of the technic believe that adjacent or intracystic cancers might be overlooked or fear that tract seeding might occur on those oc-
casions when malignant tumors were needled. Supporters of the technic find it an expeditious and safe method of managing a common disorder. Such has been the experience of NRMC Hospital, Portsmouth, where cyst aspiration has become an important screening tool in a breast clinic that cares for thirtyfive to fifty patients weekly. Surgeons who adopt cyst aspiration as a diagnostic and treatment modality acknowledge the existence of intracystic and mural cancers but believe that the incidence of these lesions is so small that their consideration has little stance against the potential benefit from aspiration [5]. Outpatient Biopsy. On the appointed day, a brief history and physical examination are recorded, and parenteral premeditations are given. Biopsy is performed under local anesthesia in the main operating suite. An immediate frozen tissue study is obtained, and if a malignant tumor is found, the patient is admitted for further evaluation and definitive treatment. Occasionally, the diagnosis on frozen section is deferred. In these instances the patient is sent home to await final decision. Local anesthesia biopsy is not the procedure of choice for every patient. Some solid lesions appear clearly to be malignant on physical examination, and this group is ordinarily selected for biopsy under general anesthesia. If the lesion is quite bulky or deeply located in the breast, it is best managed under general anesthesia. Certain personality patterns must also be considered, and the surgeon must evaluate his patient’s anxiety over awakening to find a breast gone against that of remaining awake while the issue is resolved.
Fromthe Departments of Surgery and the Clinical Investigation Service, Naval Hospital, Naval Regional Medical Center, Portsmouth, and Eastern Virginia Medical School, Norfolk, Virginia. Reprint requests should be addressed to Robert W. Knapp, CAPT MC USN, Department of Surgery. Naval Hospital, Portsmouth, Virginia 23708.
The Naval Hospital, Portsmouth, experience in breast biopsy over 114 months (June 1963 to January 1973) in-
626
Clinical Material
cludes a total of 2,492 biopsies performed for dominant breast lesions, 179 of which were selected for general an-
The American Journal of Surgery
Breast Biopsy
Of these 179,79 (44 per cent) were found to be cancers. Of the total, 2,313 biopsies were performed under local anesthesia on outpatients; 94 cancers (4.1 per cent) were found in these 2,313 biopsies. The average age of patients whose surgery was performed under local anesthesia was 33.7 years (range, 25 to 77 years; mean, 34 years). The average age of patients who underwent surgery under general anesthesia was 48.1 years (range, 25 to 84 years; mean, 47 years). The delay between biopsy and definitive surgery in the patients under local anesthesia ranged from zero to fortysix days (mean, 1 day; average, 4.1 days). Seventy-five patients had biopsies under local anesthesia on more than one occasion during the study period. In two of these individuals, cancer was found on the second biopsy in the same breast. esthesia.
Follow-Up Eighty-nine patients in whom breast cancer was diagnosed were followed five years or longer. Of these, fifty-eight individuals had their tumors detected under local anesthesia, and their five year survival was 72.4 per cent. The five year survival rate for the thirty-one patients who had malignant tumors diagnosed under general anesthesia biopsy was 48.4 per cent. The statistics in both groups include as dead of cancer any patients lost to follow-up. Figure 1 compares the survival curves of the fifty-eight Portsmouth patients whose cancers were diagnosed under local anesthesia against a group of Columbia Stage A patients [7]. This comparison is made because the Portsmouth patients selected for local anesthesia biopsy fall essentially within that
SURVIVAL
Figure 1. Survival after radical mastectomy. Asterisk indicates data based on a group of Coiwnbia Stage A patients at Ellis Fischei State Caker Hospital [S].
vobma 131. May 1976
level of clinical staging, although the selection of anesthetic is not made solely on clinical findings. All patients had radical mastectomy.
Comments The age difference between patients who had biopsies performed under local anesthesia and those who had general anesthesia reflects selection: lesions of lower suspicion that occur in younger persons having been selected for local technic. A five year survival of 72 per cent is believed to compare satisfactorily with accepted data [8]. Thus, the act of local anesthesia biopsy does not itself affect survival adversely. There is a wide difference between the survival rates for the local anesthesia and general anesthesia biopsy patients, but this again represents selection and does not indicate a salutory effect of the local technic. The advantages of the method lie in other areas, and it suffices to show that the method does not have a negative effect on survival. Concern has been raised that local anesthesia breast biopsy might compromise survival rates or enhance local recurrences because of the delay between biopsy and definitive treatment. In similar studies comparing immediate and delayed mastectomy, no difference in survivals was found [9,10]. Survival and local recurrence experience at Naval Hospital, Portsmouth, is consistent with this finding. Considering additional laboratory work, anesthetist’s fee, x-ray films, and hospital room charges, it is calculated that a breast biopsy under general
AFTER
Years
RADICAL
Following
MASTECTOMY
Mastectomy
627
Knapp and Mullen
anesthesia in a hospitalized patient costs two or three times as much as does the same procedure under local anesthesia through the Outpatient Department. We believe the benefits from selective use of local anesthesia biopsy fall in three areas, one nebulous and impossible to evaluate, and the other two practical and concrete. (1) The use of a simplified plan for breast biopsy may have a single great value: the surgeon who employs such a technic may tend to biopsy earlier in the course of the disease. (2) There was no significant morbidity nor any mortality from either of the anesthetic methods in the cases presented, yet we must concede that the potential risk of general anesthesia is greater even in the most skilled hands. The Portsmouth experience shows that the use of a selective program for breast biopsy results in a thirteen-fold reduction in the number of general anesthetics needed to accomplish a given number of biopsies. (3) The use of local anesthesia permits the addition of another member, the patient, to the decisionmaking team. Inclusion of the patient’s opinion in preoperative planning has not always been the surgeon’s way, but as public awareness of medical matters has increased, such practice is more to be considered. This applies in particular to breast cancer surgery in which an informed public has been sensitized to professional disagreement over methods of treatment. Based on the data and comments presented, we recommend a much wider use of needle aspiration and a selective use of biopsy under local anesthesia for the evaluation of dominant breast masses.
626
Summary A plan is advocated for the management of the dominant breast mass with use of local anesthesia in the outpatient setting as the primary diagnostic tool, but with selection of certain patients for immediate general anesthesia biopsy in the “conventional” manner. Experience with this plan in 2,492 patients during a period of 114 months shows local anesthesia biopsy to be efficient and accurate. Five year survival for all mastectomy-treated patients whose cancers were diagnosed under local anesthesia is 72 per cent. Use of a triage method for selecting biopsy procedures has resulted in a thirteen-fold decrease in the number of patients subjected to general anesthesia References 1. Abramson DJ: Eight hundred fifty-seven breast biopsies as an outpatient procedure: delayed mastectomy in 41 malignant cases. Ann Surg 163: 476, 1966. 2. Rupnik EJ. Williams EL, Johnson WC: Breast biopsy: an outpatient procedure using local anesthesia. MM AM 133: 743. 1968. 3. Saltzstein EC, Man RW, Chua TY. DeCosse JJ: Outpatient breast biopsy. Arch Surg 109: 267. 1974. 4. Caffee HI-I, Benfiekl JR: Data favoring biopsy of the breast under local anesthesia. Surg Gynecot Obstet 140: 88, 1975. 5. Botton JP: The breast cyst and the hospital bed. Arch Surg 10 1: 382, 1970. 6. Rosemond GP, Maier WP, Brobyn TJ: Needle aspiration of breast cysts. Surg Gynecol Obstet 126: 35 1, 1969. 7. Rush BL: Principles of Surgery, 2nd ed. New York, McGraw-Hill, 1974, p 422. 6. Spratt JS. Donegan WL: Cancer of the Breast. Philadelphia, WB Saunders, 1967, p 119,. 9. Pierce EH, Clagett OT, McDonald JR. Gage RP: Biopsy of the breast followed by delayed radical mastectomy. Surg Gynecol Obstet 103: 559, 1956. 10. Jackson PP, Pitts HH: Biopsy with delayed radical mastectomy for carcinoma of the breast. Am J Surg 96: 164, 1959.
The American Journal ef Surgery
Triage for the Breast Biopsy CAP1 Robert W. Knapp, MC USN, Portsmouth, Virginia CAP1 Joseph T. Mullen, MC USN, Portsmouth, Virginia
Local anesthesia has been used with relative infrequency in the United States to obtain histologic information on dominant breast masses. The approach to these lesions that has seemed most appropriate to American’ surgeons has been hospital admission and preparation for possible radical mastectomy. Biopsy under general anesthesia is performed, and cancers, if proved on frozen section, are usually treated surgically under the same anesthetic. During the past decade, investigators have questioned the “traditional” approach to breast biopsy and have proposed a greater use of local anesthesia for the initial operation [1,2]. Recent reports indicate a greater current interest in breast biopsy under local anesthesia than has been previously expressed [3,4]. In 1963, the Surgical Service at Naval Hospital, Naval Regional Medical Center (NRMC), Portsmouth, Virginia, abandoned the routine use of general anesthesia for breast biopsy. A method of management was developed that is based on two concepts. (1) Needle aspiration is attempted on threedimensional lesions. Any mass that does not yield fluid and disappear entirely is biopsied immediately. (2) Most biopsies are performed under local anesthesia on outpatients. Certain patients are selected for “standard” biopsy, under general anesthesia on the basis of high probability of malignancy or other reasons. Aspiration of Cysts. The useof needleaspiration to evacuate breast cysts has been advocated by some surgeons for years, but although most operators have used the method occasionally, few have adopted it as a routine [5,6]. Opponents of the technic believe that adjacent or intracystic cancers might be overlooked or fear that tract seeding might occur on those oc-
casions when malignant tumors were needled. Supporters of the technic find it an expeditious and safe method of managing a common disorder. Such has been the experience of NRMC Hospital, Portsmouth, where cyst aspiration has become an important screening tool in a breast clinic that cares for thirtyfive to fifty patients weekly. Surgeons who adopt cyst aspiration as a diagnostic and treatment modality acknowledge the existence of intracystic and mural cancers but believe that the incidence of these lesions is so small that their consideration has little stance against the potential benefit from aspiration [5]. Outpatient Biopsy. On the appointed day, a brief history and physical examination are recorded, and parenteral premeditations are given. Biopsy is performed under local anesthesia in the main operating suite. An immediate frozen tissue study is obtained, and if a malignant tumor is found, the patient is admitted for further evaluation and definitive treatment. Occasionally, the diagnosis on frozen section is deferred. In these instances the patient is sent home to await final decision. Local anesthesia biopsy is not the procedure of choice for every patient. Some solid lesions appear clearly to be malignant on physical examination, and this group is ordinarily selected for biopsy under general anesthesia. If the lesion is quite bulky or deeply located in the breast, it is best managed under general anesthesia. Certain personality patterns must also be considered, and the surgeon must evaluate his patient’s anxiety over awakening to find a breast gone against that of remaining awake while the issue is resolved.
Fromthe Departments of Surgery and the Clinical Investigation Service, Naval Hospital, Naval Regional Medical Center, Portsmouth, and Eastern Virginia Medical School, Norfolk, Virginia. Reprint requests should be addressed to Robert W. Knapp, CAPT MC USN, Department of Surgery. Naval Hospital, Portsmouth, Virginia 23708.
The Naval Hospital, Portsmouth, experience in breast biopsy over 114 months (June 1963 to January 1973) in-
626
Clinical Material
cludes a total of 2,492 biopsies performed for dominant breast lesions, 179 of which were selected for general an-
The American Journal of Surgery
Breast Biopsy
Of these 179,79 (44 per cent) were found to be cancers. Of the total, 2,313 biopsies were performed under local anesthesia on outpatients; 94 cancers (4.1 per cent) were found in these 2,313 biopsies. The average age of patients whose surgery was performed under local anesthesia was 33.7 years (range, 25 to 77 years; mean, 34 years). The average age of patients who underwent surgery under general anesthesia was 48.1 years (range, 25 to 84 years; mean, 47 years). The delay between biopsy and definitive surgery in the patients under local anesthesia ranged from zero to fortysix days (mean, 1 day; average, 4.1 days). Seventy-five patients had biopsies under local anesthesia on more than one occasion during the study period. In two of these individuals, cancer was found on the second biopsy in the same breast. esthesia.
Follow-Up Eighty-nine patients in whom breast cancer was diagnosed were followed five years or longer. Of these, fifty-eight individuals had their tumors detected under local anesthesia, and their five year survival was 72.4 per cent. The five year survival rate for the thirty-one patients who had malignant tumors diagnosed under general anesthesia biopsy was 48.4 per cent. The statistics in both groups include as dead of cancer any patients lost to follow-up. Figure 1 compares the survival curves of the fifty-eight Portsmouth patients whose cancers were diagnosed under local anesthesia against a group of Columbia Stage A patients [7]. This comparison is made because the Portsmouth patients selected for local anesthesia biopsy fall essentially within that
SURVIVAL
Figure 1. Survival after radical mastectomy. Asterisk indicates data based on a group of Coiwnbia Stage A patients at Ellis Fischei State Caker Hospital [S].
vobma 131. May 1976
level of clinical staging, although the selection of anesthetic is not made solely on clinical findings. All patients had radical mastectomy.
Comments The age difference between patients who had biopsies performed under local anesthesia and those who had general anesthesia reflects selection: lesions of lower suspicion that occur in younger persons having been selected for local technic. A five year survival of 72 per cent is believed to compare satisfactorily with accepted data [8]. Thus, the act of local anesthesia biopsy does not itself affect survival adversely. There is a wide difference between the survival rates for the local anesthesia and general anesthesia biopsy patients, but this again represents selection and does not indicate a salutory effect of the local technic. The advantages of the method lie in other areas, and it suffices to show that the method does not have a negative effect on survival. Concern has been raised that local anesthesia breast biopsy might compromise survival rates or enhance local recurrences because of the delay between biopsy and definitive treatment. In similar studies comparing immediate and delayed mastectomy, no difference in survivals was found [9,10]. Survival and local recurrence experience at Naval Hospital, Portsmouth, is consistent with this finding. Considering additional laboratory work, anesthetist’s fee, x-ray films, and hospital room charges, it is calculated that a breast biopsy under general
AFTER
Years
RADICAL
Following
MASTECTOMY
Mastectomy
627
Knapp and Mullen
anesthesia in a hospitalized patient costs two or three times as much as does the same procedure under local anesthesia through the Outpatient Department. We believe the benefits from selective use of local anesthesia biopsy fall in three areas, one nebulous and impossible to evaluate, and the other two practical and concrete. (1) The use of a simplified plan for breast biopsy may have a single great value: the surgeon who employs such a technic may tend to biopsy earlier in the course of the disease. (2) There was no significant morbidity nor any mortality from either of the anesthetic methods in the cases presented, yet we must concede that the potential risk of general anesthesia is greater even in the most skilled hands. The Portsmouth experience shows that the use of a selective program for breast biopsy results in a thirteen-fold reduction in the number of general anesthetics needed to accomplish a given number of biopsies. (3) The use of local anesthesia permits the addition of another member, the patient, to the decisionmaking team. Inclusion of the patient’s opinion in preoperative planning has not always been the surgeon’s way, but as public awareness of medical matters has increased, such practice is more to be considered. This applies in particular to breast cancer surgery in which an informed public has been sensitized to professional disagreement over methods of treatment. Based on the data and comments presented, we recommend a much wider use of needle aspiration and a selective use of biopsy under local anesthesia for the evaluation of dominant breast masses.
626
Summary A plan is advocated for the management of the dominant breast mass with use of local anesthesia in the outpatient setting as the primary diagnostic tool, but with selection of certain patients for immediate general anesthesia biopsy in the “conventional” manner. Experience with this plan in 2,492 patients during a period of 114 months shows local anesthesia biopsy to be efficient and accurate. Five year survival for all mastectomy-treated patients whose cancers were diagnosed under local anesthesia is 72 per cent. Use of a triage method for selecting biopsy procedures has resulted in a thirteen-fold decrease in the number of patients subjected to general anesthesia References 1. Abramson DJ: Eight hundred fifty-seven breast biopsies as an outpatient procedure: delayed mastectomy in 41 malignant cases. Ann Surg 163: 476, 1966. 2. Rupnik EJ. Williams EL, Johnson WC: Breast biopsy: an outpatient procedure using local anesthesia. MM AM 133: 743. 1968. 3. Saltzstein EC, Man RW, Chua TY. DeCosse JJ: Outpatient breast biopsy. Arch Surg 109: 267. 1974. 4. Caffee HI-I, Benfiekl JR: Data favoring biopsy of the breast under local anesthesia. Surg Gynecot Obstet 140: 88, 1975. 5. Botton JP: The breast cyst and the hospital bed. Arch Surg 10 1: 382, 1970. 6. Rosemond GP, Maier WP, Brobyn TJ: Needle aspiration of breast cysts. Surg Gynecol Obstet 126: 35 1, 1969. 7. Rush BL: Principles of Surgery, 2nd ed. New York, McGraw-Hill, 1974, p 422. 6. Spratt JS. Donegan WL: Cancer of the Breast. Philadelphia, WB Saunders, 1967, p 119,. 9. Pierce EH, Clagett OT, McDonald JR. Gage RP: Biopsy of the breast followed by delayed radical mastectomy. Surg Gynecol Obstet 103: 559, 1956. 10. Jackson PP, Pitts HH: Biopsy with delayed radical mastectomy for carcinoma of the breast. Am J Surg 96: 164, 1959.
The American Journal ef Surgery
