Preoperative Evaluation

Preoperative needle biopsy and breast imaging should be performed before breast cancer surgical treatment. Despite clinical suspicion of a malignancy, either by clinical examination or imaging test, it is important that a preoperative biopsy be obtained. Masses can be biopsied by fine needle aspiration or core needle biopsy. Core needle biopsy is preferable because information on invasion, hormone receptor status, tumor grade, and in some cases, lymphovascular invasion can be evaluated. Core needle biopsies can be guided by palpation for palpable masses or by stereotactic or sonographic guidance for mammo-graphic or ultrasound abnormalities, respectively. In contemporary management, upward of 85% of breast cancers should be diagnosed preoperatively. A cancer diagnosis before initial surgical treatment leads to more definitive local excision, a wider resection, a greater proportion with negative tumor margins, a decreased need for re-excision, and the ability to evaluate the axilla simultaneously.11 Patients can also be appropriately counseled before surgery regarding choices such as breast conservation versus mastectomy and neoadjuvant therapy, if appropriate.

However, there are some instances in which a preoperative cancer diagnosis may not be feasible. A stereotactic biopsy for suspicious or indeterminate microcalcifications may not be technically feasible because of proximity to the skin or chest wall. These patients should proceed directly to needle localization and excision. Additionally, approximately 25% of patients with a preoperative needle biopsy may be upstaged to malignancy after surgical excision. A radiologic diagnosis of radial scar mandates surgical excision because of the difficulty in differentiating a radial scar from a low grade lesion on core needle biopsy. Finally, patients with clotting abnormalities should probably proceed directly to surgery instead of a preoperative needle biopsy.

Although many patients are diagnosed based on imaging abnormalities, there are still a few patients who present with a palpable mass. All patients with breast cancer should have, at minimum, a mammogram. A mammogram permits evaluation of the breast for disease outside the affected quadrant and may provide an estimate of tumor size. Disease outside the affected quadrant precludes the use of breast conservation and may be helpful in planning surgical treatment.

The role of magnetic resonance imaging (MRI) in the patient newly diagnosed with breast cancer is still being debated.12 Preoperative breast MRI may be used to evaluate the ipsilateral or contralateral breast. Additional tumor can be identified in the ipsilateral breast in 13% to 31%13-22 of patients resulting in a wider excision in 3% to 14% or conversion to mastectomy in up to 25%.18,21-23 These results have suggested that candidates for breast conservation surgery should have a preoperative breast MRI. However, it is unclear if the occult disease identified on breast MRI is clinically important and would not be adequately treated with whole breast radiotherapy. Long-term local recurrence for patients treated with breast conservation is approximately 10%, which is significantly lower than the rate of additional tumor identified on breast MRI. A small retrospective study reported a higher local recurrence rate of 6.8% in women who had conventional imaging compared with 1.2% in those who had received a preoperative MRI (P < 0.01).24 However, these rates of local recurrence are quite low and different from the series reported by Solin and colleagues where preoperative MRI at the time of diagnosis was not associated with any improvement in outcome.25 There are even fewer data regarding the role of breast MRI to detect occult disease in the contralateral breast. The largest study addressing this issue comes from the American College of Radiology Imaging Network (ACRIN),26 In which occult contralateral disease was identified in 3.1% of participants. The mean diameter of the invasive tumors was 1 cm and was not influenced by menopausal status, dense breast tissue, or tumor histology. At the present time, there is no convincing evidence to suggest that the use of preoperative MRI improves local control in women, but it may permit better definition of extent of disease and decrease the need for re-excision to obtain negative surgical margins.

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  • Category: Women's diseases