Excisional Biopsy / Needle-Localized Excision
What the Examiner Expects
Surgical removal of a breast lesion for diagnostic or therapeutic purposes, often guided by a localization device (wire, radioactive seed, or radar reflector) for nonpalpable lesions. The examiner expects you to know that core needle biopsy has largely replaced excisional biopsy for initial diagnosis, but excisional biopsy remains indicated for discordant imaging-pathology results, lesions not amenable to core biopsy, and high-risk lesions requiring complete excision (atypical ductal hyperplasia, papilloma, radial scar). A specimen radiograph must confirm the target lesion is within the excised tissue.
Key Examiner Focus Points
- Wire-localized or seed-localized excision for nonpalpable lesions
- Obtain specimen radiograph to confirm lesion is within the specimen
- Orientation with sutures/clips for margin assessment
- If core biopsy shows ADH or papilloma at clip site, excision is diagnostic, not therapeutic
- Increasingly replaced by percutaneous core needle biopsy for diagnosis
Common Curveballs
Core biopsy shows atypical ductal hyperplasia (ADH)
ADH on core biopsy has a 15–20% upgrade rate to DCIS or invasive cancer on excision. Surgical excision is mandatory to rule out an adjacent malignancy. This is NOT a final diagnosis.
Specimen radiograph does not show the clip/calcifications
The target was missed. Additional tissue must be excised. Re-image the cavity and the specimen. If the clip is still in the breast, re-excise with new localization guidance. Do not close until the target is confirmed in the specimen.
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