D. Scott Lind, M.D., F.A.C.S.; Barbara L. Smith, M.D., Ph.D., F.A.C.S.; Wiley W. Souba, M.D., Sc.D., F.A.C.S.


ACS Surgery 


The procedures used to diagnose, stage, and treat breast disease are rapidly becoming less radical, less invasive, and, possibly, more precise. Breast imaging procedures -- such as mammography, ultrasonography, and magnetic resonance imaging -- are playing increasingly important roles in management, and any surgeon currently treating patients with breast disease should have a working knowledge of all of these modalities. In many surgical practices, breast ultrasonography and ultrasound-guided biopsy are now routinely performed. Ductoscopy and ductal lavage, though less well established than ultrasonography, are nonetheless promising: their predictive value and clinical utility are not yet clearly defined, but it appears that they can provide important information regarding the status of the breast duct epithelium.[1] Excisional breast biopsy has largely been supplanted by fine-needle aspiration (FNA) biopsy for palpable breast lesions and by percutaneous biopsy for nonpalpable breast lesions. Stereotactic and ultrasound-guided core-needle biopsies are less invasive and less costly alternatives to open surgical biopsies for most patients with nonpalpable breast lesions from which tissue must be acquired.[2]

Breast conservation has supplanted mastectomy for local breast treatment in most patients. Updates of multiple prospective, randomized trials involving thousands of breast cancer patients continue to demonstrate that survival after lumpectomy and radiation therapy does not differ significantly from survival after mastectomy.[3] Local recurrence rates after lumpectomy and radiation therapy range from 3% to 10%, depending on selection criteria. Even though most women with breast cancer are candidates for breast conservation, some either require or prefer mastectomy. Advances in reconstructive techniques have led to significantly improved outcomes after breast reconstruction.[4] In addition, management of the axilla has changed dramatically since the early 1990s, and sentinel lymph node (SLN) biopsy has virtually replaced routine axillary dissection.[5] Finally, various percutaneous extirpative and ablative local therapies have been developed for managing breast cancer in certain carefully selected patients. The roles of these therapies remain to be defined, and investigations are currently under way.[6]

In what follows, we describe selected standard, novel, and investigational procedures employed in the diagnosis and management of breast disease. The application of these procedures is a dynamic process that is shaped both by technological advances and by our evolving understanding of the biology of breast diseases.


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