When is surgical excision recommended?

When Surgical Excision is Recommended

Surgical excision is recommended when core needle biopsy shows indeterminate lesions, imaging-pathology discordance, high-risk histologies (ADH, pleomorphic LCIS, papillary lesions, radial scars with atypia), lesions increasing in size during surveillance, or when definitive treatment is needed for confirmed malignancies. 1

Breast Lesions

Mandatory Surgical Excision Scenarios

• Indeterminate lesions on core biopsy require surgical excision regardless of imaging appearance 1
• Imaging-pathology discordance (benign biopsy result that doesn't match suspicious imaging) mandates excision 1, 2
• Atypical ductal hyperplasia (ADH) identified on core biopsy requires surgical excision 1
• Pleomorphic LCIS or LCIS/ALH with imaging discordance requires excision 1
• Multiple-foci LCIS involving >4 terminal ductal units on core biopsy (associated with increased invasive cancer risk) requires excision 1

High-Risk Lesions Requiring Selective Excision

• Mucin-producing lesions, potential phyllodes tumors, papillary lesions, and radial scars may require excisional biopsy based on pathologist concern 1
• Papillomas in high-risk patients (prior/concurrent atypia or cancer, high-risk status) should undergo surgical excision due to 10.7% upgrade rate to high-risk lesions and 3.9% upgrade to DCIS 3
• Pure radial scars that are concordant and benign do NOT require excision (0% upgrade rate), but radial scars with additional high-risk lesions have 4.2% upgrade rate and should be excised 4

Surveillance Failures

• Benign lesions that increase in size during 6-12 month follow-up require surgical excision 1
• Persistent clinical suspicion despite negative imaging warrants tissue biopsy, and if lesion increases, proceed to excision 1

Hepatocellular Carcinoma (HCC)

Non-Cirrhotic Liver

• Single peripheral or central lesions: Surgical excision by partial hepatectomy is standard treatment 1
• Multifocal disease: No standard treatment exists; percutaneous techniques or chemo-embolization are options, not surgical excision 1

Cirrhotic Liver - Child-Pugh A

• Unifocal HCC <5 cm: Surgical excision should be undertaken if at all possible within a specialist setting 1
• Multifocal HCC (≤3 lesions <5 cm): Surgical excision is recommended for peripheral tumors specifically 1

Cirrhotic Liver - Child-Pugh B

• Small lesions: Percutaneous techniques are preferred over surgical excision 1
• Larger lesions: Hepatic transplantation or chemo-embolization are options; surgical excision carries higher risk 1, 5

Cirrhotic Liver - Child-Pugh C

• Surgical excision is NOT recommended; palliative hormone therapy or symptomatic treatment only 1

Bone and Soft Tissue Sarcomas

Osteosarcoma

• High-grade osteosarcoma: Complete surgical excision is mandatory as part of multimodal treatment with chemotherapy 1
• Recurrent osteosarcoma with isolated lung metastases or local recurrence: Treatment is primarily surgical 1

Ewing Sarcoma

• Complete surgical excision when feasible is the best modality of local tumor control rather than radiation therapy alone 1
• Extraskeletal Ewing sarcoma: Follows same surgical principles as bone Ewing sarcoma 1

Chondrosarcoma

• High-grade chondrosarcomas and all pelvic/axial skeleton chondrosarcomas should be surgically excised with wide margins 1
• Atypical cartilaginous tumors: Can be managed by curettage with or without local adjuvant therapy 1

GIST (Gastrointestinal Stromal Tumors)

• Tumors ≥2 cm: Biopsy or excision is the standard approach 1
• Localized GIST: Complete surgical excision (en bloc resection with no rupture) is standard treatment, with no lymph node dissection needed 1
• Rectal GIST: Biopsy and local treatment should always be considered regardless of size 1

Basal Cell Carcinoma (BCC)

Low-Risk BCC

• Standard excision with 4-mm clinical margins achieves >95% complete removal for well-circumscribed lesions <2 cm 1
• Linear closure, skin grafting, or second intention healing are appropriate if recommended margins achieved 1
• If tissue rearrangement needed for closure: Intraoperative surgical margin assessment (Mohs surgery) is necessary before closure 1

High-Risk BCC

• Mohs micrographic surgery is the preferred surgical technique (1.0% recurrence for primary, 5.6% for recurrent BCC at 5 years) 1
• Standard excision with wider margins can be used if Mohs unavailable, but expect increased recurrence rates 1

Common Pitfalls to Avoid

• Do not perform curettage and electrodesiccation if subcutaneous layer is reached during surgery; convert to surgical excision 1
• Do not delay breast lesion excision when imaging-pathology discordance exists, even if biopsy shows "benign" findings 1, 2
• Do not assume all papillomas are benign; excise in high-risk patients or those with concurrent atypia 3
• Do not perform surgical resection in Child-Pugh C cirrhosis; focus on palliative measures 1
• Do not excise pure radial scars when concordant and benign on core biopsy; surveillance is adequate 4