Surgeon

Full preparation includes review of all imaging studies such as mammogram, ultrasound, and MRI, as well as consultation with appropriate specialists such as the medical oncologist, radiation oncologist, and plastic surgeon. Of course reviewing all options with the patient and making sure she is understands her treatment options and is comfortable with her decision is of utmost importance. Full preparation includes review of all imaging studies such as mammogram, ultrasound, and MRI, as well as consultation with appropriate specialists such as the medical oncologist, radiation oncologist, and plastic surgeon. Of course reviewing all options with the patient and making sure she is understands her treatment options and is comfortable with her decision is of utmost importance.

I was fortunate to have my chemotherapy up front, which allowed us to actually see the tumor respond and shrink......therefore also get any cells that may have escaped (the REAL Bad Guys). This also allowed me time to really explore my surgical options. I had a fabulous general surgeon and interviewed 3 plastic surgeons. I learned that a nipple sparing mastectomy might be an option, even though I was told by at least one surgeon that it was not an option. I subsequently learned that very few surgeons do this new proceedure. Anyway, I found out through a friend of a friend of a friend (litterally) that there was a great surgeon at Emory who did the nipple sparing proceedure. I met with him and he felt that I would be a good candidate (small breasted and the tumor was far enough away from the nipple). Also, he was an oncoplastic sugeon, meaning he would do the entire proceedure himself, mastectomy and reconstruction. This meant a more cohesive surgey and less time under anesthesia. I have to say, the before and after photos did make a difference to me as well. No visible scar and a natural nipple, not a tatoo. I feel so Blessed to have even had a CHOICE. I am Blessed :o) I was his 50th nipple sparing mastectomy. I was fortunate to have my chemotherapy up front, which allowed us to actually see the tumor respond and shrink......therefore also get any cells that may have escaped (the REAL Bad Guys). This also allowed me time to really explore my surgical options. I had a fabulous general surgeon and interviewed 3 plastic surgeons. I learned that a nipple sparing mastectomy might be an option, even though I was told by at least one surgeon that it was not an option. I subsequently learned that very few surgeons do this new proceedure. Anyway, I found out through a friend of a friend of a friend (litterally) that there was a great surgeon at Emory who did the nipple sparing proceedure. I met with him and he felt that I would be a good candidate (small breasted and the tumor was far enough away from the nipple). Also, he was an oncoplastic sugeon, meaning he would do the entire proceedure himself, mastectomy and reconstruction. This meant a more cohesive surgey and less time under anesthesia. I have to say, the before and after photos did make a difference to me as well. No visible scar and a natural nipple, not a tatoo. I feel so Blessed to have even had a CHOICE. I am Blessed :o) I was his 50th nipple sparing mastectomy.

The first thing to realize, is that the term "biopsy" often means different things to different people, so hopefully I can provide some clarification as well as some advice to women who might be in this situation.

It used to be that when a woman felt a lump in her breast, she was given one option - surgery. The lump was removed, and depending on the results she either was told to resume routine follow up (if it was benign) or had a mastectomy (if it was cancer) - women used to sign a consent form that would allow for lump removal and mastectomy all at the same time if the pathology showed that it was cancer. At the time, we did not have the sophisticated imaging and biopsy devices that we do now, and there was only one operation for breast cancer - a radical or modified radical mastectomy.

Thankfully, a lot has changed. Our imaging has significantly improved - ultrasound can be invaluable when dealing with a palpable lump, especially in a young woman, as often we can make the distinction between normal "lumpy" breast tissue, a fluid-filled cyst, or a solid mass. In addition, ultrasound can give us some idea based on the characteristics of the lesion whether a solid mass is benign or malignant, but ultrasound and any imaging test does not take the place of obtaining a tissue sample that the pathologist can review to make a definitive diagnosis.

The standard of care is that minimally-invasive, image-guided biopsies be performed to make a diagnosis, not surgical removal. There are a few situations when image-guided biopsies are not technically possible or are not appropriate, but they can be performed in the majority of cases. If the biopsy demonstrates a benign lesion, the patient may not need surgery at all, or may be a candidate for a minimally invasive method of treatment, such as cryoablation (see my answer on cryoablation for more details). Approximately 80-85% of biopsies result in a benign diagnosis, and we try to reserve the operating room for therapy, not diagnosis.

If the lesion is found to be malignant, further workup such as MRI or other testing might appropriate in order to properly plan the surgery. There are also plenty of studies demonstrating that if surgery is the first procedure performed in the setting of breast cancer, the woman is more likely to require more than one operation either due to positive margins, the need for lymph node biopsy, or other factors. A more appropriate and more cosmetic procedure will be done if the diagnosis is established prior to surgery. This is supported by the American Society of Breast Surgeons (http://www.breastsurgeons.org/statements/PDF_Statements/Percutaneous_Needle_Biopsy.pdf)


As to who should perform the biopsy, surgeon or radiologist - it depends on the individual practice situation and training of the physician. More surgeons are being trained in performance of ultrasound, ultrasound-guided biopsy, and stereotactic (mammogram-guided) biopsy, and the American Society of Breast Surgeons has education, certification and accreditation programs specifically for surgeons. As a surgeon, I would rather perform the imaging and biopsy myself, as I will then have a better appreciation for exactly where the lesion is (more important when dealing with non-palpable lesions), especially if surgery is eventually required. However radiologists do perform the imaging and biopsies as well, and in many situations, work collaboratively with the surgeon.

However the most important point is not necessarily who performs the biopsy (assuming that anyone performing it is qualified), but that whenever possible, a minimally-invasive needle biopsy be performed rather than surgery as the initial procedure. The first thing to realize, is that the term "biopsy" often means different things to different people, so hopefully I can provide some clarification as well as some advice to women who might be in this situation.

It used to be that when a woman felt a lump in her breast, she was given one option - surgery. The lump was removed, and depending on the results she either was told to resume routine follow up (if it was benign) or had a mastectomy (if it was cancer) - women used to sign a consent form that would allow for lump removal and mastectomy all at the same time if the pathology showed that it was cancer. At the time, we did not have the sophisticated imaging and biopsy devices that we do now, and there was only one operation for breast cancer - a radical or modified radical mastectomy.

Thankfully, a lot has changed. Our imaging has significantly improved - ultrasound can be invaluable when dealing with a palpable lump, especially in a young woman, as often we can make the distinction between normal "lumpy" breast tissue, a fluid-filled cyst, or a solid mass. In addition, ultrasound can give us some idea based on the characteristics of the lesion whether a solid mass is benign or malignant, but ultrasound and any imaging test does not take the place of obtaining a tissue sample that the pathologist can review to make a definitive diagnosis.

The standard of care is that minimally-invasive, image-guided biopsies be performed to make a diagnosis, not surgical removal. There are a few situations when image-guided biopsies are not technically possible or are not appropriate, but they can be performed in the majority of cases. If the biopsy demonstrates a benign lesion, the patient may not need surgery at all, or may be a candidate for a minimally invasive method of treatment, such as cryoablation (see my answer on cryoablation for more details). Approximately 80-85% of biopsies result in a benign diagnosis, and we try to reserve the operating room for therapy, not diagnosis.

If the lesion is found to be malignant, further workup such as MRI or other testing might appropriate in order to properly plan the surgery. There are also plenty of studies demonstrating that if surgery is the first procedure performed in the setting of breast cancer, the woman is more likely to require more than one operation either due to positive margins, the need for lymph node biopsy, or other factors. A more appropriate and more cosmetic procedure will be done if the diagnosis is established prior to surgery. This is supported by the American Society of Breast Surgeons (http://www.breastsurgeons.org/statements/PDF_Statements/Percutaneous_Needle_Biopsy.pdf)


As to who should perform the biopsy, surgeon or radiologist - it depends on the individual practice situation and training of the physician. More surgeons are being trained in performance of ultrasound, ultrasound-guided biopsy, and stereotactic (mammogram-guided) biopsy, and the American Society of Breast Surgeons has education, certification and accreditation programs specifically for surgeons. As a surgeon, I would rather perform the imaging and biopsy myself, as I will then have a better appreciation for exactly where the lesion is (more important when dealing with non-palpable lesions), especially if surgery is eventually required. However radiologists do perform the imaging and biopsies as well, and in many situations, work collaboratively with the surgeon.

However the most important point is not necessarily who performs the biopsy (assuming that anyone performing it is qualified), but that whenever possible, a minimally-invasive needle biopsy be performed rather than surgery as the initial procedure.