Breast procedures are performed by almost all general surgeons, and they can be summarized by brief discussions of the following: palpable lumps, mammographic abnormalities, and breast cancer.
An excisional biopsy involves the complete removal of a lump, whereas an incisional biopsy involves the sampling of tissue to yield a diagnosis. A needle biopsy is therefore incisional and is usually performed on lumps that are suspicious.
A palpable lump may be solid, cystic, or complex (solid and cystic.) A palpable lump that is cystic can be aspirated and observed if it disappears completely with aspiration, if the aspirate is not bloody, and if it does not recur.
Mammograms are categorized as screening and diagnostic. Worrisome findings include a non-palpable mass and suspicious calcifications, and needle biopsy techniques utilize ultrasound or conventional radiographic imaging.
A small clip is deployed at the time of the needle biopsy for future localization if needed. The procedure is done under local anesthesia, and patients can return to work in two days. Benign reports are observed, and a suspicious report requires a “wire directed” excisional biopsy. A small gauge wire is used to localize the clip, and the surgeon then uses the wire as a guide to completely remove the lump (“lumpectomy”). The procedure is done under anesthesia as an outpatient.
Mastectomies are no longer routinely performed for breast cancer, and most patients choose to have a lumpectomy if they are suitable candidates. Likewise, complete lymph node dissections are no longer routinely performed unless the nodes are palpable. The nodal basin is sampled (sentinel lymph node mapping) using blue dye at the time of the mastectomy or lumpectomy. The administration of chemotherapy and radiation is based upon the final pathology report.
Finally, breast cancer can present as swelling, as a rash, as a nipple discharge, and as a palpable mass that is not seen on mammography or ultrasound.