If a breast lesion cannot be felt but needs to be removed, it needs to be localized prior to surgery. This can be done for cancers or benign lesions. When done for a cancer, the procedure involves removing more normal surrounding tissue (wide local excision). For a benign lesion, the reason for excision is usually to obtain a full biopsy of the lesion for pathological analysis. In this case, we try to remove the lesion without too much of the normal surrounding tissue. It is called an excisional biopsy.
There are a few techniques to do so which are institution-dependant (ie. Depend on which hospital you are having your procedure at). These include ROLLIS (Radioguided Occult Lesion Localisation using iodine-125 seeds), Magseed (using a magnet to detect the lesion) and guidewire localisation. The most common technique is using a long needle called a guidewire.
Under imaging guidance and local anaesthetic infiltration, the needle is introduced into the lesion. A “hook” is then deployed at the end of the needle which fixes this wire in place until it is removed together with the lesion during the surgery. This is why it can also be called a “hookwire-guided excision”. This is performed one to two hours before your procedure.
Once the lesion is surgically removed, it is sent for an x-ray to ensure the lesion has been removed adequately.
The position, size and shape of the scar will depend on the position and size of the tumour or lump as well as the size of the breast. It will also depend on whether the surgery is done for a benign lump or a known breast cancer.
Most of the time, the tumour can be removed through a simple incision bringing the breast tissue back together with a good cosmetic outcome.
However, larger tumours require more complex techniques to achieve these aims. These techniques borrow from the plastic surgery techniques used in breast reduction (mammaplasty) and breast lift (mastopexy) techniques. These surgical techniques are called oncoplastic surgery (onco= related to cancer, plastics = plastic surgical techniques).
The likely surgical technique including final scar position and expected breast size will be discussed with you prior to surgery.
The breast lesion is sent for a specimen x-ray or ultrasound then to the laboratory for pathological analysis under the microscope.
Risks of surgery
There is a small risk of bleeding which usually settles spontaneously.
There is also a small risk of infection which is further reduced by the administration of antibiotics at the time of surgery.
Following an excisional biopsy, further surgery may be required depending on the diagnosis and whether or not the whole lesion has been removed.
Following a wide local excision, up to 10% of patients may have a positive margin when examined under the microscope. This usually requires further surgery – either removing more tissue or sometimes a mastectomy.
Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.
If your procedure includes a sentinel node biopsy, you will be booked for a lymphoscintigram – on the morning of surgery for an afternoon procedure, or the afternoon before for a morning procedure.
If you require placement of a guidewire, this will be done one to two hours before your procedure. It will be co-ordinated with your lymphoscintigram if you require both.
You will be informed of your admission time which will depend on the above procedures.
Pain is usually minimal following a wide local excision but may be more significant after more extensive oncoplastic surgery.
You should take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).
Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.
Stronger pain killers such as opioid anaelgesics (Endone, Codeine) are usually not required and should be taken sparingly as they can cause constipation.
The wound is dressed with Dermabond glue which is waterproof. The glue feels hard which is normal. It sheds off over the 2-3 weeks.
Most wide local excisions and lumpectomies do not require drainage. However, some patients may require placement of a drain tube following more extensive oncoplastic techniques such as a breast reduction.
You can usually go home the same day unless the technique used involved a breast reduction or symmetrizing surgery to the opposite breast. This may require you to stay overnight.
You will be followed up within 1-2 weeks of your surgery to review the wound and discuss your pathology results.
Your follow up appointment is usually made for you prior to discharge.