area of interest is then prepped and anesthetized with lidocaine injected in the skin and along the

planned needle path. Using a No. 11 blade, a small stab incision is made. The needle is then advanced

through the skin puncture site and toward the center of the lesion on the basis of the computed

calculations. The needle is advanced to the leading edge of the lesion and its position is verified by

imaging. Following biopsy, repeat images are obtained to ensure that the area of concern has been

adequately biopsied. The procedure may be repeated to obtain additional cores. Most stereotactic core

biopsies are performed with vacuum assistance allowing for greater accuracy. If suspicious

microcalcifications are biopsied, the samples can be examined with specimen imaging to ensure the

presence of microcalcifications within the biopsy samples. At the completion of the procedure, manual

compression is used to obtain hemostasis, and the skin nick is closed with adhesive strips with a

transparent medical dressing. An ice pack and compression dressing can also be used.

Failure to obtain an adequate sample can result in a false-negative test result, although the falsenegative rate is very low. In some instances, the results of the core biopsy may not be definitive and a

surgical excision is required. If the core biopsy demonstrates a concerning lesion, surgical biopsy is

required to exclude a diagnosis of malignancy. In the clinical context of persistent suspicious physical

examination or imaging abnormalities (discordance between clinical and/or imaging findings and

pathology results), surgical excision is required. Please see Table 74-2 for indications for surgical

excision after core biopsy.

Incisional Biopsy

Incisional biopsy typically involves surgical removal of part of a large mass for diagnosis. With the

advent of core needle biopsy techniques, incisional biopsy is rarely required. However, if a core needle

biopsy is nondiagnostic and the mass is too large to remove without significant cosmetic compromise,

an incisional biopsy can be performed for definitive diagnosis.

INDICATIONS/CONTRAINDICATIONS

Table 74-2 Indications for Surgical Biopsy After Core Biopsy

Excisional Biopsy

Excisional biopsy of the breast is the surgical removal of a breast lesion. Although core needle biopsy

has largely obviated the need for excisional biopsy for diagnostic considerations, indications for this

procedure still remain. Indications include breast lesions that are presumed to be benign but require

excision, discordance between clinical evaluation/diagnostic imaging and pathology requiring further

tissue sampling, high-risk lesions (including atypical ductal hyperplasia, radial scar, and papilloma)

identified on core biopsy, abnormalities that are close to the nipple or chest wall, small breasts that are

not amenable to core biopsy (given the needle excursion is often 2 cm), and for patients who cannot

tolerate stereotactic core needle biopsy. In addition, excisional biopsy may be considered for complex

cysts, aspirated cysts that do not completely resolve, and when follow-up imaging for a lesion with

previous benign pathology from a core biopsy shows an increase in size or has suspicious changes.

Excisional biopsies may also be performed for likely benign lesions that are greater than 2 cm, painful,

or recurring, or where the mass represents growing cysts or fibroadenomas. Patient preference for

complete removal of a benign lesion may also be an indication for excisional biopsy.

For nonpalpable lesions, the abnormality can be localized preoperatively using a needle localization

wire that is placed with the patient in a sitting position with the breast compressed by a labeled grid

plate. Various needles used include the Kopans needle (check mark wire), the Hawkins needle (multiple

barbs and the only retractable wire for repositioning), and the Homer needle (J wire and

nontransectable needle). For lesions that are superficial and can be readily imaged by ultrasound, needle

2041

localization can be performed under ultrasound guidance. The patient is then taken to the operative

setting, where excision of the lesion can be performed under local anesthesia with sedation or general

anesthesia. In the operating room, the patient is placed in the supine position with the arm ipsilateral to

the index lesion positioned at 90 degrees. Appropriate padding of the arm and wrists should be

undertaken. The operative site is then prepped and draped in a sterile fashion. Intraoperative

localization is performed by evaluating the imaging studies and palpating the needle (for nonpalpable

lesions) or by direct palpation. For lesions located in the upper half of the breast, transverse or

curvilinear incisions are made along Langer’s lines. If an incision is needed in the lower half of the

breast, radial incisions are used. When possible, periareolar or inframammary incisions are made as they

result in the best cosmesis. Prior to incision, a local anesthetic is injected into the skin and along the

path of the needle localization wire. The incision is then typically made directly above the palpable

mass or the tip of the needle (Fig. 74-10). Alternatively, an incision can be made next to the needle and

then followed down to its tip to find the target lesion. Once the skin incision is made, the thickest

possible flaps, which would still result in fully removing the lesion anteriorly, are developed. The

specimen is then excised with electrocautery. The specimen is oriented with sutures, with the short

stitch designating the superior margin and the long stitch designating the lateral margin. Palpation of

the cavity is performed to ensure complete removal of the lesion. Specimen imaging is performed to

confirm excision of the lesion of interest. The skin is closed in two layers. Cyanoacrylate tissue adhesive

is then applied, allowing the patient to take a shower within 24 hours. For allergies to skin glue,

adhesive strips can be applied. No pressure dressing is needed. A sports bra may be worn to stabilize the

breast for the first 48 hours.

Skin Punch Biopsy

For any suspicious cutaneous lesion of the breast or chest wall, a biopsy can be obtained using a punch

biopsy device, which consists of a circular blade. Punch biopsy devices are available in various sizes

ranging from 1 mm to 8 mm, with the 2-mm and 4-mm size most commonly used in breast biopsies. The

area to be biopsied is first selected. Common sites are the most abnormal-appearing site within a lesion

or the edge of an actively growing lesion. The involved skin is cleansed and infiltrated with 2 to 3 mL

of 1% lidocaine. The punch device is held vertically over the skin and rotated downward using a

twirling motion until the subcutaneous fat or the hub of the device is reached. The specimen is then

transected at the base with iris scissors. The skin is approximated with an interrupted stitch or U-stitch.

Figure 74-10. Incision placement for needle localization biopsy. A: The mammogram demonstrates that the lesion (arrow) is

inferior to the point of wire entry. B: Incision placement inferior to wire entry to allow access to the lesion.

COMMON CLINICAL PROBLEMS AND MANAGEMENT ALGORITHMS

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The most common clinical breast problems include breast masses, breast pain, nipple discharge, and

breast infections. Clinical algorithms for the evaluation of these common breast problems have been

developed to facilitate optimal care.

Breast Mass

A breast mass is defined as a palpable area in the breast that may be either benign or malignant. When a

woman presents with a palpable breast finding, a thorough history and physical examination needs to be

performed. The history should include a thorough review of the patient’s medical problems and any risk

factors associated with breast cancer (see the section on Management of Patients at High Risk for Breast

Cancer).

In women younger than 35 years with no family history of premenopausal breast cancer or other risk

factors, a targeted ultrasound is an appropriate initial imaging approach for a breast mass that appears

clinically benign (Algorithm 74-1). The ultrasound is used to determine whether a dominant mass is

present, as normal glandular tissue of the breast, especially in young women, may feel nodular. In a

review of 605 women younger than 40 years who were referred for evaluation of a breast mass, only

36% of the masses detected by patients had a surgical correlate. Furthermore, only 29% of the masses

detected by primary care providers were confirmed.51 Consideration can then be made regarding the

need for additional imaging such as mammography or an MRI. In women aged 35 years or older, the

initial imaging approach to a palpable mass should include mammography and ultrasound. These studies

should be obtained prior to any biopsies are performed as postbiopsy changes can distort subsequent

imaging evaluation. Of note, all clinically suspicious palpable masses need to be biopsied even in the

absence of imaging findings as 15% of breast cancers can be mammographically occult (Algorithm 74-

2).46 Ultrasound also provides important information about the etiology of a breast mass and can

further categorize the mass as either cystic or solid. Workup of a cystic lesion typically involves

aspiration of the cyst, with further evaluation based on the results of the aspiration (Algorithm 74-3).

The definitive diagnosis of a breast mass is often confirmed by a core needle biopsy, although FNA is an

appropriate alternative (Table 74-3). Core needle biopsy is typically preferred to excisional biopsy.

TREATMENT

Table 74-3 Management of Breast Masses Based on Core Biopsy Diagnosis

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Algorithm 74-1. Diagnosis and management of the patient with a clinically benign breast mass. The use of imaging studies varies

according to age because breast carcinoma is infrequent in women younger than 35 years old.

Algorithm 74-2. Diagnosis and management of the patient with a clinically indeterminate or suspicious solid breast mass. In this

circumstance, imaging studies are insufficient to exclude malignancy, and tissue sampling is required.1

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Algorithm 74-3. Diagnosis and management of the patient with a cystic lesion. Bloody fluid on aspiration, failure of the mass to

resolve completely, and prompt refilling of the same cyst are indications for surgical biopsy.

Breast cysts are common causes of dominant masses in premenopausal and perimenopausal women. If

a cyst is found in a postmenopausal woman in the absence of hormone therapy use, it should be

regarded with a high degree of suspicion. Palpable masses that present as benign solid masses include

fibroadenomas, fibrocystic disease, and fat necrosis. Fibrocystic breast disease has been used to describe

a variety of benign breast disorders associated with nodular breast tissue. This term, however, should be

reserved for women who have a biopsy consistent with one of the histologic components of fibrocystic

change. Breast surgery, blunt trauma, injection of native or foreign substance such as fat and silicone,

and radiation therapy can result in fat necrosis. On clinical examination and mammographic imaging,

fat necrosis can mimic a malignancy, often leading to a biopsy. However, when oil cysts, which are

circumscribed masses of mixed soft tissue density and fat with a calcified rim, are present

radiographically, a definitive diagnosis of fat necrosis can be made (Fig. 74-11). See the section on

Benign Breast Disease.

Breast Pain

Breast pain (mastalgia, mastodynia, idiopathic breast pain) is a common concern and is rarely (0.5% to

3.3%) representative of a breast cancer. It is noted that some IBCs can present with pain. While twothirds of patients present with cyclical breast pain, another one-third has pain that is unrelated to the

menstrual cycle and more likely to be secondary to a breast or chest wall lesion.52

Cyclical breast pain is associated with hormonal changes during the menstrual cycle and often occurs

the week prior to the onset of menses and often dissipates once menstrual flow is established. During

the menstrual cycle, the breast undergoes significant histologic changes as described by Vogel et al. (see

the section on Menstrual Cycle).31 During the secretory phase, luminal cells produce apocrine secretions

and the stromal cells become edematous, which may contribute to the pathogenesis of breast pain.

However, the exact physiologic events are not understood completely. Furthermore, while most women

do experience mild cyclical breast pain, it is not clear why others have more pronounced pain. Cyclical

breast pain is typically bilateral and involves the upper outer aspect of the breasts with radiation to the

axillae or down the arms.

Noncyclical breast pain is more frequently unilateral and variable in its location in the breast. Possible

etiologies include large pendulous breasts with pain resulting from stretching of the Copper’s ligaments,

duct ectasia, macrocysts, medications (including antidepressants, hormones, and antibiotics), and

infections.53,54 Thrombophlebitis of the lateral thoracic or superior thoracoepigastric vein (Mondor

disease) is an uncommon presentation for breast pain characterized by a tender subcutaneous cord in the

lateral aspect of the breast (Fig. 74-12). Mondor disease may result from trauma, radiation to the

breast, and/or breast surgery. It can also occur in women with nonpalpable breast cancers, and a

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mammogram should be obtained when diagnosed.55 For symptomatic relief, a patient can use antiinflammatory medications, although Mondor disease often resolves spontaneously without the need for

a specific therapy. Referred pain to the breast from the chest wall or ribs can also occur. Spinal or

paraspinal problems and medical conditions (biliary, pulmonary, esophageal, and cardiac disease) can

also result in referred pain.

Figure 74-11. Oil cysts. The calcified rims of these cysts in a patient with a history of trauma are diagnostic.

Figure 74-12. Mondor disease. Thrombophlebitis of the thoracoepigastric vein causes retraction of the lateral portion of the breast,

which crosses to the midline at the inferior areolar margin and is accompanied by a palpable cord.

The workup for breast pain should include a careful history, including questions related to the

menstrual cycle, a thorough physical examination, and in women 35 years of age and older, a

mammogram. If a malignancy is suspected, biopsy should be performed. If the CBE and diagnostic

imaging studies are normal, reassurance that the symptoms are not consistent with breast cancer often

provides significant relief for the patient.

Initial therapy for idiopathic breast pain includes lifestyle changes, the use of supportive garments

such as a well-fitting brassiere with a steel underwire, a low-fat high-carbohydrate diet, and elimination

of caffeine and nicotine. Oral analgesics with acetaminophen or nonsteroidal anti-inflammatory drugs

(NSAIDs) should be initiated. Topical analgesic gels containing diclofenac or salicylate can be applied to

the affected breast areas. If a patient is on oral contraceptives or hormone replacement therapy,

discontinuation of these medications may improve pain. However, in women not using oral

contraceptives with cyclical breast symptoms, the initiation of this therapy has been shown to reduce

breast pain severity and duration. Although inconclusive evidence exists for the role of evening

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primrose oil (3,000 mg daily),56,57 it is often part of the initial therapeutic approach. Evening primrose

oil needs to be taken for at least 4 to 6 months to achieve a positive effect.

Approximately 5% of women will still have debilitating breast pain despite lifestyle changes and the

initial therapies described above. For these women, therapies such as danazol, tamoxifen,

bromocriptine, and gonadotropin-releasing hormone (GnRH) agonists can be considered. However, only

danazol has been approved by the FDA for the treatment of idiopathic breast pain. Danazol (100 mg to

400 mg daily) is an antigonadotropin that results in a hypoestrogenic state. However, its use is often

discontinued as it also induces a hyperandrogenic state, with most women having side effects of

increased facial hair, acne, deepening of the voice, and adverse blood lipid profiles.58 Tamoxifen (10 mg

daily) has also been shown to be effective although side effects, including the risk of blood clots,

endometrial cancer, and hot flashes limit its use.59 As both danazol and tamoxifen have significant

teratogenic effects, women on these therapies must be counseled to use an effective birth control

method. Although bromocriptine and GnRH agonists have been studied for use in breast pain, they are

not currently recommended because of significant side effects. Therapies that have been proven to be

ineffective include diuretics, progesterone, and vitamins. Surgery to excise trigger spots (in the absence

of an identifiable lesion) is not recommended, as the affected area is often replaced by a painful scar.

Nipple Discharge

Nipple discharge is a common breast symptom that often results in surgical consultation. The most

common cause of pathologic nipple discharge is an intraductal papilloma, but breast cancer can also

present as a pathologic nipple discharge. The first step in evaluation of nipple discharge is to determine

whether the nipple discharge is pathologic or physiologic. Physiologic discharge is nonspontaneous or is

elicited by manual compression of the nipple. It often involves multiple ductal orifices in the nipple and

is present in both breasts. The discharge is commonly white or clear (although it can also present as

yellow, green, brown, or gray fluid) and is negative on occult blood test. In contrast, pathologic nipple

discharge is spontaneous, is present in a single breast/ductal orifice, and is often positive on occult

blood test. However, any nipple discharge that is spontaneous is considered pathologic. Age is also

predictive of breast cancer risk in women with nipple discharge. In a study involving women with

pathologic nipple discharge, breast cancer was present in 3% of women younger than 40 years, 10% in

those 40 to 60 years of age, and 32% in those older than 60 years.60

Clinical evaluation of nipple discharge includes a careful history and physical examination. The

history includes questions regarding whether the discharge is spontaneous or elicited, unilateral or

bilateral. The patient should be questioned regarding any recent trauma to the breast. The medical

history and medications are reviewed. Medications such as oral contraceptives, metoclopramide,

phenothiazines, and selective serotonin reuptake inhibitors can be associated with nipple discharge. A

premenopausal woman presenting with milky fluid discharge bilaterally or galactorrhea should be

evaluated for endocrine disease. Hypogonadism as suggested by amenorrhea or hot flashes/vaginal

dryness should prompt a workup for hyperprolactinemia. In addition, hypothyroidism, pituitary

adenoma, and chest trauma (including thoracotomy) can result in galactorrhea. When endocrine disease

is suspected, patients should undergo laboratory evaluation including quantitative hCG, prolactin level,

and thyroid function tests. The physical examination should include a visual field test as often these

patients may show signs of bitemporal field loss or chiasmal syndrome. A careful breast examination is

performed to evaluate for any dominant masses, skin changes such as eczema/infections, nipple changes

such as Paget disease, or adenopathy. Each of the quadrants of the involved breast is massaged from the

periphery to the nipple areolar complex and then pressure is applied to the base of the nipple areolar

complex to elicit discharge. This will help define the involved quadrant of the breast and whether the

discharge is from a single ductal orifice. The color of any nipple discharge should be noted, and an

occult blood test should be performed.

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Figure 74-13. Ductogram. A large defect (arrows) represents an intraductal papilloma.

After initial evaluation, no further workup is required in women who have physiologic discharge, and

these women should be advised to avoid manual compression of the nipples.

Imaging evaluation is indicated for patients with pathologic nipple discharge and includes an

ultrasound, and for patients older than 30 years, a mammogram is also recommended. In patients with

an imaging abnormality, a biopsy should be considered. Additional diagnostic tests that may be helpful

include ductography and ductoscopy. Ductography is performed by instilling contrast medium into the

involved duct to identify any lesions in the ductal system. Lesions will appear as a complete ductal

obstruction, irregularities in the duct wall, or as an intraductal filling defect (Fig. 74-13). However, the

absence of a lesion on ductography does not rule out a cancer.61 Ductoscopy is often performed in the

operating room and involves the use of a small fiberoptic ductoscope that is placed into the involved

duct. The benefit of ductoscopy is that it allows for direct visualization of any potential lesions, which

may result in more precise excision.

The most common etiology of pathologic nipple discharge is a papilloma, which is a benign epithelial

lesion with supporting stroma that grows within a duct. When a papilloma is diagnosed by core biopsy,

the standard recommendation is to proceed with surgical excision as it may be associated with atypia or

ductal carcinoma in situ (DCIS). Other causes for pathologic nipple discharge include malignancy (most

commonly DCIS, 5% to 15% of cases) and duct ectasia, which is characterized by ductal dilatation with

loss of elastin in the duct walls and the presence of chronic inflammatory cells. It is not known,

however, whether the inflammatory cells result from a primary or secondary infection and antibiotics

are not recommended.

If a malignancy is identified as the etiology of a pathologic nipple discharge, it should be managed

accordingly with the appropriate cancer surgery typically as the first treatment. In the absence of a

known malignancy, pathologic nipple discharge should be treated with terminal duct excision. Prior to

excision, the patient should refrain from any nipple stimulation. If the involved duct can be identified

intraoperatively, a lacrimal duct or instillation of methylene blue may aid with the duct excision.

Terminal duct excision is commonly performed with a circumareolar incision and involves removal of

the duct from its proximal to distal extent, which is often a distance of 2 to 3 cm. Alternatively,

ductoscopy can be performed as previously prescribed and then the outer sheath of the cannula can be

left in place as a guide for surgical excision of the involved duct. If there is difficulty isolating the

involved duct or multiple ducts are involved, central or total terminal duct excision may be indicated.

The potential risks of terminal duct excision include inability to breast-feed and hyposensitivity or

hypersensitivity of the nipple.

Breast Infections

Breast infections are uncommon outside of the postpartum period. As such, breast infections can be

classified as lactating or nonlactating infections. Lactating breast infections occur commonly during the

initial 6 weeks of breast-feeding and during the process of weaning. In the initial stages of infection, a

mastitis or cellulitis is typically found, with associated pain, erythema, induration, and fever. A woman

should not be counseled to discontinue breast-feeding. Commonly, the cellulitis results from

Staphylococcus aureus. Treatment includes pain management (acetaminophen, NSAIDs) and an antibiotic

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