The Pros and Cons of Outpatient Breast
Biopsy
Sister Mary Ann Lou, MD; Ashis K. Mandal, MD; Joseph L. Alexander, MD
\s=b\ A review of the 130 breast biopsies performed on women during the past three years at the Martin Luther King, Jr, General Hospital showed that 90 were performed on outpatients and 40 on inpatients. Of the 90 outpatient procedures, 61 were under local anesthesia and 29 under general. Only three outpatient biopsy specimens were malignant and required subsequent patient admission to the hospital for mastectomy at an interval of 9 to 14 days. In all three, the axillary nodes were uninvolved. In two, no residual tumor was found in the mastectomy specimen. Whereas during this period patients with clinically suspected malignant neoplasms of the breast were admitted for biopsy, we are, considering all the advantages of outpatient biopsy and the accumulating evidence that the interval between biopsy and mastectomy is harmless, expanding the outpatient biopsy procedure to include tumors suspected of malignancy. (Arch Surg 111:668-670, 1976)
has been considerable anguish and financial cost patients who underwent the conventional route of "excisional breast biopsy and possible radical mastectomy," even though the majority of breast biopsy specimens are benign. The few who advocated a more simplified route are like voices crying in the wilderness.1"4 Why is the medical profession reluctant to adopt breast biopsy as an outpatient procedure? This report shows how this practice developed at our institution and how the selection criteria evolved.
There
to many
Accepted for publication Feb 12, 1976. From the Division of General Surgery, Department of Surgery, Los Angeles County-Martin Luther King, Jr, General Hospital, and the Charles R. Drew Postgraduate Medical School, Los Angeles. Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, Jan 17, 1976. Reprint requests to Department of Surgery, Martin Luther King, Jr, General Hospital, Los Angeles, CA 90059 (Sister Mary Ann Lou).
SUBJECTS AND METHODS Between October 1972 and December 1975, a total of 130 breast
biopsies were performed on women at our hospital. Ninety of these outpatient basis and 40 on inpatient. All were done in the operating room, under local or general anesthesia. We began outpatient surgery shortly after our hospital opened in 1972, when the patient load outgrew our bed capacity. Initially, only young patients with clinically benign breast lesions were selected to have biopsies performed on an outpatient basis under local anesthesia, but in the main operating suite to ensure aseptic technique and hemostasis. If the surgeon or patient was unwilling to accept local anesthesia, the biopsy was done on an inpatient basis under general anesthesia in the conventional way. Later on, as general anesthesia was extended to ambulatory surgical patients, and attitudes changed, even older patients with slightly suspicious lesions were included. Most of the cysts were excluded
were on an
from biopsy after aspiration was done in the clinic. Patients with highly suspicious lesions were admitted to the hospital for evalua¬ tion and biopsy of the lesions in the conventional manner. Recently, we became more inclined to do needle biopsy of a very large or highly suspicious mass in the clinic. We have no experi¬ ence with needle aspiration cytology. The routine developed for outpatient surgery included complete blood cell count, urinalysis, an abbreviated history, physical exam¬ ination, and written consent for surgery. The patient was given written instructions to take nothing by mouth preoperatively and to bring a companion who could take her home. On the day of operation, the patient's vital signs were checked by the clinic staff, and the absence of upper respiratory infection and skin infection was verified. The patient put on a gown and was sent to the preanesthesia area, where the surgeon reexamined the breast mass, and the anesthesia staff started an intravenous infusion and gave the premedication. We prefer to have an anesthetist stand by even for local anesthesia cases. Postoperatively, the patient was routinely observed in the recovery room for at least 30 minutes after local anesthesia and longer after general anesthesia. When fully alert and able to walk, she was discharged to the clinic, with the surgeon's written postoperative instructions concerning diet, activity, medication, dressing care, and return appointment date.
Downloaded From: http://archsurg.jamanetwork.com/ by a Yale University User on 05/17/2015
Table 1.—Breast
Biopsies*
Table
2.—Outpatient Breast Biopsies
No. of Patients
Pathologic Diagnosis
Method of Anesthesia
,_-"-,
Outpatient Inpatient
Local
Total 90
61 1
40t
General 29 37
Diagnosis of Carcinoma
Lipoma
14
*
Performed at Martin Luther King, Jr, General Hospital from Octo¬ ber 1972 to December 1975. t Includes two needle biopsies for overt carcinoma.
The clinic staff would make sure that the patient and her companion understood the instructions and would have the prescriptions filled; she was then discharged home. The written instructions were essential, as many patients could not remember everything the doctor said, due to nervousness or medication. The operative technique that evolved included the following: the patient was prepared and draped in the regular operating room setting. When general anesthesia was chosen, intubation was usually not necessary. When local anesthesia was chosen, 1% lidocaine (Xylocaine) plain field block was preferred. The infiltra¬ tion was given 2.5 cm away from the mass, so as to keep the mass palpable for easy removal. Epinephrine was not used, for fear of delayed bleeding. Circumareolar incision was used whenever possible, to obtain the best cosmetic results. Electrocautery was used for meticulous hemostasis. The breast tissue was approxi¬ mated if the cavity was large, and the skin was closed with subcuticular polyglycolic acid (Dexon). Occasionally, a Penrose drain was used, which would be removed the next day in the clinic. The patient was instructed to leave the 2 2-gauge inner dressing intact, but to remove the outer pressure dressing the next
morning. RESULTS
outpatient biopsies, 61 were done under local under general anesthesia (Table 1). The 29 anesthesia, patients' ages ranged from 14 to 69 years, averaging 26.4 years. Three of the outpatient biopsy specimens were malignant and required subsequent patient admission to the hospital for mastectomy. The interval between biopsy and mastectomy ranged from 9 to 14 days. All had negative findings from metastatic workup. All three had negative axillary nodes. Only one had residual tumor in the mastec¬ tomy specimen. All 40 inpatient biopsies were done under general anesthesia, except one done under local anesthesia and two needle biopsies. The ages ranged from 17 to 82 years, averaging 46.7 years. Of these 40 cases, 14 were diagnosed as malignant, and the patients underwent Of the 90
mastectomy (including three simple); six had positive axillary nodes. The pathologic diagnosis of the outpatient biopsy spec¬ imens was predominantly fibroadenona (Table 2). When more than one pathologic entity was present in the speci¬ was classified under the dominant lesion. Neither the inpatient nor the outpatient biopsies resulted in complications, such as wound infection or hematoma requiring evacuation, although a few had remarkable ecchymosis.
men, it
COMMENT Our limited
experience
indicated that
outpatient
Fibroadenoma
Sclerosing adenosis Fibrocystic disease
breast
Lactating adenoma Duct papilloma Carcinoma Total
No. of Patients 65 14 3 3 1 1 3 go
biopsy can be safely and conveniently done, when an outpatient surgical routine is established. Advantages for the patient are that (1) women with a breast lump may seek medical attention sooner, if they know diagnosis could be less costly, emotionally and finan¬ cially; (2) patients seldom refuse surgery when it is offered on an outpatient basis; many prefer to know the definitive diagnosis before participating in the decision of mastec¬ tomy; (3) patients can avoid the unnecessary mental suffering of consenting to "possible radical mastectomy," when, for the majority, only a biopsy is needed; (4) outpatient surgery obviates the personal and family incon¬ venience of a hospital admission, lessens the disruption of family routine or time lost from work; and (5) the financial cost of an outpatient biopsy is only about one fifth of the cost of a two-day hospital stay, although the surgeon's fee may be the same. The patient could also avoid the cost of the frozen section, the prolonged general anesthesia while waiting for the frozen section verdict, and perhaps unnec¬ essary medical evaluations and metastatic workup. The advantages for the surgeon are real also. It saves him time and emotional strain from lengthy discussion about possible mastectomy to patients, the majority of whom will not need it, yet have to sign an informed consent. It facilitates the operating room scheduling and preparations, since time, room, and instruments need not be set aside in anticipation of possible mastectomy. The surgeon avoids the wait and the possible error of frozen section. Even if malignancy is diagnosed at outpatient biopsy, probably no harm is done. The surgeon can then proceed with the metastatic workup and preoperative
medical evaluation and offer a more precise and wiser plan patient concerning the definitive treatment. There are a few disadvantages for the patient. The disadvantage of needing someone to accompany her is more apparent than real, since the presence of a friend or relative can be a source of strength and support. Discom¬ fort of local anesthesia is sometimes unavoidable, but can be lessened by adequate premedication, good rapport with a gentle surgeon, and a standby anesthetist. When general anesthesia or a supplemental intravenous analgesic is used, the patient may become oversedated and remain in the recovery room too long. This possibility can be lessened by alerting the anesthetist to use only short-acting agents for outpatients. Some hospital insurance policies do not cover outpatient surgery. This problem is diminishing as insur¬ ance companies are becoming aware of the mutual benefits of allowing outpatient surgery. There is possible risk to the
to the
Downloaded From: http://archsurg.jamanetwork.com/ by a Yale University User on 05/17/2015
patient's chance of cure if cancer cells were seeded in tissue planes during biopsy, when mastectomy is not immediately
done. However, the accumulated evidence has been to the contrary.38 The disadvantages for the surgeon are few. It is distressing for the surgeon if the patient experiences an undue amount of pain during operation under local anes¬ thesia. This can be lessened by proper patient selection, improved infiltration anesthesia technique, and having an anesthetist stand by. A small or deep mass may become obscured by the local anesthetic solution and become difficult to find or missed. This can be avoided by injecting at least 2.5 cm away from the palpable mass during field block. If the anesthetist is unwilling to stand by, the surgeon must conduct of the
assume
more
caution in the choice and
procedure. Since general anesthesia can be extended to outpatient surgical procedures, our criteria for outpatient surgery has been much simplified: (1) the patient should be ambu¬ latory before and after the operation; (2) the patient should have no serious associated medical problems; and (3) the postoperative care should not require professional skills available only in the hospital environment. Thus, outpa¬ tient breast biopsy need not be restricted to younger
patients, nor restricted to benign lesions. However, for breast biopsy to be done under local anesthesia, the criteria for patient selection are that the patient be willing and able to cooperate (this excludes patients who are emotion¬ ally unstable, retarded, or having a language barrier); and that the breast mass be palpable (this excludes lesions detectable only by mammography). We do not recommend local anesthesia for quadrant biopsy, nor for a deep mass in very large breasts, nor for very large or multiple lesions, where the amount of anesthetic solution required may exceed the maximum safety limits. CONCLUSIONS
In the face of soaring medical costs and increasing public of the problems of breast lumps, outpatient excisional biopsy of the majority of solid lesions should be seriously considered. Cysts should be aspirated. A needle biopsy should be performed on obvious carcinoma. From our experience, the pros and cons are presented, and selection criteria are suggested. The human elements among the surgeon, the patient, and the anesthetist remain to be worked out as a cooperative endeavor for this procedure to be generally accepted in this country. awareness
References 1. Saltzstein EC, Mann RW, Chua TY, et al: Outpatient breast biopsy. Arch Surg 109:287-290, 1974. 2. Fleming RM: Breast biopsy\p=n-\anoutpatient procedure? J Florida Med Assoc 61(suppl 3):238, 1974. 3. Crile G Jr, Esselstyn CB, Hermann RE, et al: A new look at biopsy of the breast. Am J Surg 126:117-119, 1973. 4. Earle AS: Delayed operation for breast carcinoma. Surg Gynecol Obstet 131:291, 1970. 5. Abramson DJ: Eight hundred fifty-seven breast biopsies as an outpa-
tient
procedure: Delayed mastectomy
163:478-483, 1966.
in 41
malignant
cases.
Ann
Surg
6. Goldman WP: Triple biopsy for carcinoma of the breast: A clinical 200 cases. Surgery 70:628-634, 1971. 7. Brennan MJ: Breast cancer, in Holland JF, Frei E III(eds): Cancer Medicine. Philadelphia, Lea and Febiger, 1973, p 1777. 8. Jackson PP, Pitts HH: Biopsy with delayed radical mastectomy for carcinoma of the breast. Am J Surg 98:184-189, 1959.
study of
Downloaded From: http://archsurg.jamanetwork.com/ by a Yale University User on 05/17/2015
Biopsy
Sister Mary Ann Lou, MD; Ashis K. Mandal, MD; Joseph L. Alexander, MD
\s=b\ A review of the 130 breast biopsies performed on women during the past three years at the Martin Luther King, Jr, General Hospital showed that 90 were performed on outpatients and 40 on inpatients. Of the 90 outpatient procedures, 61 were under local anesthesia and 29 under general. Only three outpatient biopsy specimens were malignant and required subsequent patient admission to the hospital for mastectomy at an interval of 9 to 14 days. In all three, the axillary nodes were uninvolved. In two, no residual tumor was found in the mastectomy specimen. Whereas during this period patients with clinically suspected malignant neoplasms of the breast were admitted for biopsy, we are, considering all the advantages of outpatient biopsy and the accumulating evidence that the interval between biopsy and mastectomy is harmless, expanding the outpatient biopsy procedure to include tumors suspected of malignancy. (Arch Surg 111:668-670, 1976)
has been considerable anguish and financial cost patients who underwent the conventional route of "excisional breast biopsy and possible radical mastectomy," even though the majority of breast biopsy specimens are benign. The few who advocated a more simplified route are like voices crying in the wilderness.1"4 Why is the medical profession reluctant to adopt breast biopsy as an outpatient procedure? This report shows how this practice developed at our institution and how the selection criteria evolved.
There
to many
Accepted for publication Feb 12, 1976. From the Division of General Surgery, Department of Surgery, Los Angeles County-Martin Luther King, Jr, General Hospital, and the Charles R. Drew Postgraduate Medical School, Los Angeles. Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, Jan 17, 1976. Reprint requests to Department of Surgery, Martin Luther King, Jr, General Hospital, Los Angeles, CA 90059 (Sister Mary Ann Lou).
SUBJECTS AND METHODS Between October 1972 and December 1975, a total of 130 breast
biopsies were performed on women at our hospital. Ninety of these outpatient basis and 40 on inpatient. All were done in the operating room, under local or general anesthesia. We began outpatient surgery shortly after our hospital opened in 1972, when the patient load outgrew our bed capacity. Initially, only young patients with clinically benign breast lesions were selected to have biopsies performed on an outpatient basis under local anesthesia, but in the main operating suite to ensure aseptic technique and hemostasis. If the surgeon or patient was unwilling to accept local anesthesia, the biopsy was done on an inpatient basis under general anesthesia in the conventional way. Later on, as general anesthesia was extended to ambulatory surgical patients, and attitudes changed, even older patients with slightly suspicious lesions were included. Most of the cysts were excluded
were on an
from biopsy after aspiration was done in the clinic. Patients with highly suspicious lesions were admitted to the hospital for evalua¬ tion and biopsy of the lesions in the conventional manner. Recently, we became more inclined to do needle biopsy of a very large or highly suspicious mass in the clinic. We have no experi¬ ence with needle aspiration cytology. The routine developed for outpatient surgery included complete blood cell count, urinalysis, an abbreviated history, physical exam¬ ination, and written consent for surgery. The patient was given written instructions to take nothing by mouth preoperatively and to bring a companion who could take her home. On the day of operation, the patient's vital signs were checked by the clinic staff, and the absence of upper respiratory infection and skin infection was verified. The patient put on a gown and was sent to the preanesthesia area, where the surgeon reexamined the breast mass, and the anesthesia staff started an intravenous infusion and gave the premedication. We prefer to have an anesthetist stand by even for local anesthesia cases. Postoperatively, the patient was routinely observed in the recovery room for at least 30 minutes after local anesthesia and longer after general anesthesia. When fully alert and able to walk, she was discharged to the clinic, with the surgeon's written postoperative instructions concerning diet, activity, medication, dressing care, and return appointment date.
Downloaded From: http://archsurg.jamanetwork.com/ by a Yale University User on 05/17/2015
Table 1.—Breast
Biopsies*
Table
2.—Outpatient Breast Biopsies
No. of Patients
Pathologic Diagnosis
Method of Anesthesia
,_-"-,
Outpatient Inpatient
Local
Total 90
61 1
40t
General 29 37
Diagnosis of Carcinoma
Lipoma
14
*
Performed at Martin Luther King, Jr, General Hospital from Octo¬ ber 1972 to December 1975. t Includes two needle biopsies for overt carcinoma.
The clinic staff would make sure that the patient and her companion understood the instructions and would have the prescriptions filled; she was then discharged home. The written instructions were essential, as many patients could not remember everything the doctor said, due to nervousness or medication. The operative technique that evolved included the following: the patient was prepared and draped in the regular operating room setting. When general anesthesia was chosen, intubation was usually not necessary. When local anesthesia was chosen, 1% lidocaine (Xylocaine) plain field block was preferred. The infiltra¬ tion was given 2.5 cm away from the mass, so as to keep the mass palpable for easy removal. Epinephrine was not used, for fear of delayed bleeding. Circumareolar incision was used whenever possible, to obtain the best cosmetic results. Electrocautery was used for meticulous hemostasis. The breast tissue was approxi¬ mated if the cavity was large, and the skin was closed with subcuticular polyglycolic acid (Dexon). Occasionally, a Penrose drain was used, which would be removed the next day in the clinic. The patient was instructed to leave the 2 2-gauge inner dressing intact, but to remove the outer pressure dressing the next
morning. RESULTS
outpatient biopsies, 61 were done under local under general anesthesia (Table 1). The 29 anesthesia, patients' ages ranged from 14 to 69 years, averaging 26.4 years. Three of the outpatient biopsy specimens were malignant and required subsequent patient admission to the hospital for mastectomy. The interval between biopsy and mastectomy ranged from 9 to 14 days. All had negative findings from metastatic workup. All three had negative axillary nodes. Only one had residual tumor in the mastec¬ tomy specimen. All 40 inpatient biopsies were done under general anesthesia, except one done under local anesthesia and two needle biopsies. The ages ranged from 17 to 82 years, averaging 46.7 years. Of these 40 cases, 14 were diagnosed as malignant, and the patients underwent Of the 90
mastectomy (including three simple); six had positive axillary nodes. The pathologic diagnosis of the outpatient biopsy spec¬ imens was predominantly fibroadenona (Table 2). When more than one pathologic entity was present in the speci¬ was classified under the dominant lesion. Neither the inpatient nor the outpatient biopsies resulted in complications, such as wound infection or hematoma requiring evacuation, although a few had remarkable ecchymosis.
men, it
COMMENT Our limited
experience
indicated that
outpatient
Fibroadenoma
Sclerosing adenosis Fibrocystic disease
breast
Lactating adenoma Duct papilloma Carcinoma Total
No. of Patients 65 14 3 3 1 1 3 go
biopsy can be safely and conveniently done, when an outpatient surgical routine is established. Advantages for the patient are that (1) women with a breast lump may seek medical attention sooner, if they know diagnosis could be less costly, emotionally and finan¬ cially; (2) patients seldom refuse surgery when it is offered on an outpatient basis; many prefer to know the definitive diagnosis before participating in the decision of mastec¬ tomy; (3) patients can avoid the unnecessary mental suffering of consenting to "possible radical mastectomy," when, for the majority, only a biopsy is needed; (4) outpatient surgery obviates the personal and family incon¬ venience of a hospital admission, lessens the disruption of family routine or time lost from work; and (5) the financial cost of an outpatient biopsy is only about one fifth of the cost of a two-day hospital stay, although the surgeon's fee may be the same. The patient could also avoid the cost of the frozen section, the prolonged general anesthesia while waiting for the frozen section verdict, and perhaps unnec¬ essary medical evaluations and metastatic workup. The advantages for the surgeon are real also. It saves him time and emotional strain from lengthy discussion about possible mastectomy to patients, the majority of whom will not need it, yet have to sign an informed consent. It facilitates the operating room scheduling and preparations, since time, room, and instruments need not be set aside in anticipation of possible mastectomy. The surgeon avoids the wait and the possible error of frozen section. Even if malignancy is diagnosed at outpatient biopsy, probably no harm is done. The surgeon can then proceed with the metastatic workup and preoperative
medical evaluation and offer a more precise and wiser plan patient concerning the definitive treatment. There are a few disadvantages for the patient. The disadvantage of needing someone to accompany her is more apparent than real, since the presence of a friend or relative can be a source of strength and support. Discom¬ fort of local anesthesia is sometimes unavoidable, but can be lessened by adequate premedication, good rapport with a gentle surgeon, and a standby anesthetist. When general anesthesia or a supplemental intravenous analgesic is used, the patient may become oversedated and remain in the recovery room too long. This possibility can be lessened by alerting the anesthetist to use only short-acting agents for outpatients. Some hospital insurance policies do not cover outpatient surgery. This problem is diminishing as insur¬ ance companies are becoming aware of the mutual benefits of allowing outpatient surgery. There is possible risk to the
to the
Downloaded From: http://archsurg.jamanetwork.com/ by a Yale University User on 05/17/2015
patient's chance of cure if cancer cells were seeded in tissue planes during biopsy, when mastectomy is not immediately
done. However, the accumulated evidence has been to the contrary.38 The disadvantages for the surgeon are few. It is distressing for the surgeon if the patient experiences an undue amount of pain during operation under local anes¬ thesia. This can be lessened by proper patient selection, improved infiltration anesthesia technique, and having an anesthetist stand by. A small or deep mass may become obscured by the local anesthetic solution and become difficult to find or missed. This can be avoided by injecting at least 2.5 cm away from the palpable mass during field block. If the anesthetist is unwilling to stand by, the surgeon must conduct of the
assume
more
caution in the choice and
procedure. Since general anesthesia can be extended to outpatient surgical procedures, our criteria for outpatient surgery has been much simplified: (1) the patient should be ambu¬ latory before and after the operation; (2) the patient should have no serious associated medical problems; and (3) the postoperative care should not require professional skills available only in the hospital environment. Thus, outpa¬ tient breast biopsy need not be restricted to younger
patients, nor restricted to benign lesions. However, for breast biopsy to be done under local anesthesia, the criteria for patient selection are that the patient be willing and able to cooperate (this excludes patients who are emotion¬ ally unstable, retarded, or having a language barrier); and that the breast mass be palpable (this excludes lesions detectable only by mammography). We do not recommend local anesthesia for quadrant biopsy, nor for a deep mass in very large breasts, nor for very large or multiple lesions, where the amount of anesthetic solution required may exceed the maximum safety limits. CONCLUSIONS
In the face of soaring medical costs and increasing public of the problems of breast lumps, outpatient excisional biopsy of the majority of solid lesions should be seriously considered. Cysts should be aspirated. A needle biopsy should be performed on obvious carcinoma. From our experience, the pros and cons are presented, and selection criteria are suggested. The human elements among the surgeon, the patient, and the anesthetist remain to be worked out as a cooperative endeavor for this procedure to be generally accepted in this country. awareness
References 1. Saltzstein EC, Mann RW, Chua TY, et al: Outpatient breast biopsy. Arch Surg 109:287-290, 1974. 2. Fleming RM: Breast biopsy\p=n-\anoutpatient procedure? J Florida Med Assoc 61(suppl 3):238, 1974. 3. Crile G Jr, Esselstyn CB, Hermann RE, et al: A new look at biopsy of the breast. Am J Surg 126:117-119, 1973. 4. Earle AS: Delayed operation for breast carcinoma. Surg Gynecol Obstet 131:291, 1970. 5. Abramson DJ: Eight hundred fifty-seven breast biopsies as an outpa-
tient
procedure: Delayed mastectomy
163:478-483, 1966.
in 41
malignant
cases.
Ann
Surg
6. Goldman WP: Triple biopsy for carcinoma of the breast: A clinical 200 cases. Surgery 70:628-634, 1971. 7. Brennan MJ: Breast cancer, in Holland JF, Frei E III(eds): Cancer Medicine. Philadelphia, Lea and Febiger, 1973, p 1777. 8. Jackson PP, Pitts HH: Biopsy with delayed radical mastectomy for carcinoma of the breast. Am J Surg 98:184-189, 1959.
study of
Downloaded From: http://archsurg.jamanetwork.com/ by a Yale University User on 05/17/2015
