Advanced breast biopsy instrumentation.

The August article “Advanced Breast Biopsy Instrumentation: A Critique” by Dr. George S. Ferzli and colleagues (1) raises several questions about the newest technique for imaged guided breast biopsy. We question whether there was a peer review by surgeons experienced with this technique. The authors have nicely summarized the basic steps for the ABBI procedure, but their article describes several technical errors that should have been prevented by proper education, training, and surgeon preparation. First and foremost, the ABBI biopsy should not be viewed as the diagnostic option of choice for an entire consecutive series of patients. Second, the lesion, once targeted, should never be obscured before the localizing needle is introduced and the T-fastener is deployed because no deep anesthesia is required for these steps. As with stereotactic core needle biopsy (SCNB), only dermal anesthesia should be induced during the localization sequence. Deep local anesthesia is then infiltrated and can be augmented during the procedure if a patient feels any pain during the biopsy. If the surgeon is paying attention, no patient should experience “significant discomfort during the procedure” because additional local anesthesia should be administered as soon as the patient feels pressure. Most of the “mechanical problems” that were cited in this article actually were minor problems that are inherent to any stereotactic procedures. When a hard lesion is pushed forward by the localizing needle, the needle merely should be repositioned before deployment of the T-fastener, if a T-fastener displaces a lesion, as happened in 3 of our combined 350 cases, the connecting wire should be released, the lesion retargeted, and a second ABBI unit deployed with the T-fastener released just superficial to the lesion. In this case, both T-fasteners are removed with the specimen. The ability to identify precisely these threedimensional relationships at each step of the procedure and to make swiftly appropriate adjustments speaks to the precision of the stereotactic technology and to the flexibility and versatility of the ABBI device when used properly. We cannot explain the failure of the cautery snare to cut through the specimen in 6 of 49 cases. In our series, this happened in 4 of 350 cases in very fibrous breasts. The latter cases were the only ones requiring scissor dissection in our series, and the procedures were completed while the patients were still in compression. An operating room setting has never been required. The article raises another common misconception. The ABBI biopsy does not require dissection to begin at the dermis. For a deep lesion, the proper technique begins with undermining of the tissues with scalpel dissection, so the biopsy actually begins 1–3 cm or more deep to the dermis. The real strength of this procedure is, in fact, the small size of the specimen and of the skin incision relative to open surgery; the deeper the lesion, the more these advantages are magnified. The ABBI procedure clearly is not intended to be the procedure of choice for all patients. As in every surgical procedure, and especially in every breast operation, the procedure must be tailored to the lesion, to the location within the breast, and to the desires of an informed patient. The patient