1. Fine-Needle Aspiration Biopsy

2. Incision

a. Superior Flap

b. Inferior Flap

c. Complete Resection

3. Dissection

4. Irrigation and Hemostasis

5. Closure

6. Pathology

Breast cysts are fluid-filled, round or oval sacs inside the breast, which may be due to hormonal changes. Cysts are non-cancerous and form in one or both breasts when fluid builds up inside the breast glands. They are divided into two types based on their size. Microcysts are too small to feel, but may be seen during imaging tests, such as mammography or ultrasound while macrocysts are large enough to be felt and can grow to about 2.5 to 5 cm in diameter. Large breast cysts can put pressure on nearby breast tissue, causing breast pain or discomfort. A breast lump may be palpated through clinical breast examination; however, such an exam cannot determine if the lump is cystic or solid. The cystic nature of a breast lump can be confirmed by ultrasound, mammogram, or aspiration. Examination by a cytopathologist of the fluid aspirated from the cyst may determine if it is cancerous or not. In particular, it should be sent to a laboratory for testing if it is blood-stained. Cyst fluid doesn't need to be removed unless it is causing pain or discomfort. It can be drained by inserting a needle into the cyst and removing the fluid, reducing pressure and pain. For recurrent cysts or those that cause symptoms even after aspiration of fluid, surgery to remove them is an option. Here, we are presented with a 69-year-old male who developed a lump in his right breast more than a year ago. Bloody fluid was obtained from a fine-needle aspiration biopsy of the lump, and it was sent for cytologic examination. An excision biopsy was done to remove the breast lump which was suspicious for malignancy. Histologic Examination of the specimen showed a benign lesion.

<h4>CHAPTER 1</h4>

So what we have here is a 69-year-old male who manifested with a breast mass in the right chest area for more than a year. The procedure is what is called a fine-needle aspiration biopsy wherein a needle is to be inserted in the mass to get cytological samples. So this is a very simple procedure, a very quick procedure. We only need a 10 cc syringe with a fine-needle aspiration needle, it's a gauge 23. So what we do now is somewhat sterilize the area of aspiration.

We will aspirate the breast mass with this 10 cc syringe attached to an aspirator. As you can see, the aspirate is fluid, somewhat bloody. Okay, what we have is the contents of a cystic mass, which is somewhat bloody. This is to be submitted to the laboratory for cytological examination to determine if the lesion is benign or malignant.

<h4>CHAPTER 2</h4>

Okay, we are about to start. Cautery is working.

Suction, Suction.

Good, it's fluid, huh? Yeah, it felt like a cyst. Yeah. Sorry.

No, it's a hematoma.

Okay, it's going good. Knife back.

You have another tissue? Forceps?

<h4>CHAPTER 3</h4>

Yeah, that's good.

Do you have a retractor, please? Army-Navy? Another retractor please?

Pickup? Pickup? Prepectoral Fascia. Yeah.

Tongs? Let's raise the lower flap now? The other side? Yeah.

Suction? Is it working?

Keep on coming.

We are near the skin. Yeah. Yeah. Part of the capsule is adherent to the skin. Yeah, that's fine. Then we can take more skin, we have more skin. There's fat necrosis there.

Keep on going.

Okay, now raise the flap. Yeah. Allis clamp, please? Make sure you don't get close to it. Yeah.

Good, good.

Need to stay out of the… Seems like a hemotoma for you though? Yeah. That's good. Yeah.

So now we're just dissecting - dissecting the - breast off the prepectoral fascia underneath. Pectoralis fascia.

Can we have some irrigation?

Probably just see some inflammatory tissue or something. Yeah. Yes.

Your light is much better Lester. I'll join you most other cases so that you have light. Because without your light I feel blind.

Here. Specimen.

Irrigation please?

<h4>CHAPTER 4</h4>

See the pectoralis muscles? So now we're just stopping the bleeding.

So after dissection, they noted that there's a lot of blood. So we're now thinking it might not be cancer, so which is good. So we'll find out with the pathology.

So now all of the breast tissue is gone, and now this is the pectoralis muscle. Just to show it for the medical students. Yeah. You can see the fibers of the muscle. Here are the fibers. Pectoralis muscle that comes from the sternum and the ribs, goes to the humerus, so...

Can you show your light here Lester? There is some bleeding there.

Here's the mass. See that? Yeah. We just took it out. The nipple. And the breast tissue. So we're going to send this to Dr. Cruz for pathology

Okay, good. Vicryl, please?

<h4>CHAPTER 5</h4>

We are now closing the incision site with this absorbable suture. You're doing it as a primary closure of the wound.

Mosquito please? Mosquito?

You want that cut already doc? Cut or just... Hold on to it? No, we can just run it.

We just have pressure dressing for this one? Yeah. Okay. No need for drain, or? No drain. Okay, good. Do you think we need a drain? No, I don't think so. I think we're okay. Yeah. Just do a pressure dressing. It's dry.

<h4>CHAPTER 6</h4>

At the present, I'll be taking sections from the cyst wall to determine if the lesion is benign or malignant. This will be taking about 5 to 10 minutes.

This is a microtome. This will make slides out of frozen specimens. And the slides that we can prepare will be stained, and then read under the microscope for diagnosis.

So we have tissue sections from the specimen that we got from the patient. And this now will be stained for examination.

So this is what we got from the tissue specimen. What is being seen here are histologic sections of the cyst wall showing you some benign cells there. That's actually the cyst wall. There's a lining epithelium.

So, with the tissue section examined, there are no malignant cells, and then we have to talk now to the attending to tell him that the lesion is benign, and he can end the procedure now with a plain excision biopsy of the cystic mass in the chest wall of the patient.

Watch this full-length, narrated procedure of a fine-needle aspiration biopsy and excision biopsy of a cystic breast mass in a male. Includes histological examination, which showed a benign lesion.

Romblon Provincial Hospital