Easier ways to diagnose breast cancer

Easier ways to diagnose breast cancer

Biopsy, the removal of tissue samples from the abnormal are for examination is the diagnostic step that confirms cancer. If a breast lump turns out to be cancerous, further surgery will follow to remove the entire tumour and surrounding area. Newer nonsurgical biopsy methods are now increasingly used whenever possible.

Advances in breast biopsy ease cancer diagnosis

Newer biopsy methods can often avoid the need for two surgical steps in breast cancer: one to “diagnose” the cancer, the second to remove the entire tumour and also some axillary (underarm) lymph nodes, to test for malignancy. Since the vast majority (75 per cent) of breast abnormalities biopsied turn out to be benign, clinicians prefer to avoid the discomfort and cost of surgical biopsy whenever possible. Some of the newer methods are just as accurate but quicker, cheaper, less invasive, less disfiguring and less traumatic than surgical biopsy.

The current nonsurgical breast biopsies are often done with “imaging” (X-ray or ultrasound) guidance. The methods include fine needle aspiration – using a thin needle to suck fluid and some cells out of the suspicious area – and the increasingly popular large core biopsies, in which radiologists remove larger cores of tissue under X-ray or ultrasound guidance. These methods are especially useful for small, nonpalpable (not felt by hand) abnormalities seen on mammograms or ultrasound. The procedures are quick and done in the doctor’s office or imaging (radiology) department. After a short rest, the woman can usually carry on with daily activities.

Pathologists examine the biopsy material for cancer

The breast tissue removed during biopsy is examined under a microscope by a pathologist, a physician who specializes in detecting the cellular and tissue changes that accompany disease. Pathologists can identify the presence of cancer and other diseases by analyzing abnormal cell changes under the microscope in specially prepared tissue samples. The tissue to be examined is fixed, stained and processed in various ways to detect malignancy. Typical signs of cancer seen under the microscope are cells with abnormal nuclei, strange protein clumps or radiating strands.

The larger the tissue samples obtained, the easier it is for pathologists to detect signs of cancer. If there are just a few cells for “cytological” examination, as often happens with fine needle aspiration, an abnormality may be missed. Or, the biopsy needle may skip the cancerous part, in which case a diagnosis of “no cancer,” is unreliable and must be followed by a surgical biopsy to rule out malignancy. Larger tissue samples, such as those obtained by surgery or core biopsies, allow pathologists to do a thorough histological examination (looking at cells and the tissue structure), giving more accurate results.

Given enough tissue, pathologists may be able to determine the type and stage of cancer present, whether it is still localized or invasive, aggressive or mild, and whether there are hormonal and other markers or “prognostic factors” that can help in planning treatment. If the needle biopsy result indicates cancer, the next step is surgery to remove the entire cancerous area and perhaps also the underarm lymph nodes (to check for signs of spread).

Fine needle aspiration biopsy (FNAB or FNA)

For a fine needle aspiration, the woman sits or lies on her back. The skin around the lump is swabbed with antiseptic and a fine, hollow needle is inserted into the abnormal area or lump to withdraw any fluid present and/or some cells. The cells are sent for evaluation to detect signs of cancer.

If the lump is nonpalpable (can’t be felt) then ultrasound or, less commonly, mammographic (X-ray) guidance is used to place the needle in the right spot. The whole procedure takes just a few minutes.

If the lump is a fluid-filled cyst, as breast lumps often are, needle aspiration may turn out to be the treatment as well as the diagnosis. Once the fluid is withdrawn, the fluid-filled cyst collapses and the lump may vanish. The cyst fluid ranges in colour from yellow to green to bloody and may be sent for examination. Since most cysts are benign, many physicians consider microscopic analysis of the fluid unnecessary unless it is bloody. If the cyst fluid is bloody or part of the lump remains after drainage, further biopsy may follow as there can be a malignancy lurking under or around the cyst.

If the lump is a solid mass, the physician may hold it between the fingers and push the fine needle back and forth to free some cells and suck them into the syringe. The cells withdrawn are smeared onto a glass slide for microscopic analysis or put into alcohol and then sent to the pathologist. It takes 1-7 days to get the results. If the cells obtained by FNA show definite signs of malignancy, there’s often no need for more biopsy sampling. The diagnosis is cancer, and the next step is surgery to remove the entire tumour and its surrounding margins. The simple FNA test then informs the woman that she has breast cancer, giving her time to absorb the information and discuss surgical and follow-up options. The type of surgery undertaken, its timing and follow-up treatment can be jointly planned with her medical advisors

However, fine needle aspiration has many drawbacks. All too often – in almost 30 per cent of cases – it obtains too few cells for reliable analysis. Also, pathologists tend to be less experienced in analyzing single cells than whole tissue slices. Moreover, if the result is uncertain and the needle penetrates the benign area around a cancerous nodule, the pathologist will find “no malignant changes,” amounting to a false negative result that requires further investigation. If the FNA result is inconclusive and the report states “too few cells for evaluation,” a surgical biopsy may still be needed, especially if the is a strong suspicion of cancer. Fine needle biopsies miss up to 25 per cent of cancers later identified by surgical or core biopsy, explaining why surgeons tend not to trust them and often prefer to remove the entire mass or parts of it surgically to get enough tissue for pathologists to study.

The main advantages of FNA

* Done easily and painlessly in the physician’s office or hospital imaging department; * Provides an instant cure when cysts are completely drained; * Non-invasive and doesn’t involve surgery; * Can provide quick answers if the result shows cancer, skipping the need for surgical tissue sampling.

The chief disadvantages of FNA

* Can only “harvest” isolated cells, not whole clumps of tissue. One quarter of the pathologist’s reports on FNA samples return saying “not enough tissue” (for examination). * Analysis of single cells is more difficult and less revealing than histological examination of larger tissue samples, and cannot distinguish local from invasive cancer. * Gives uncertain answers, as the needle often bypasses cancerous areas. Even multiple fine needle passes may entirely miss a cancer. * Many clinicians consider the insufficient sampling and false-negative rates of FNAB unacceptably high and insist on a core or surgical biopsy, in which case FNA becomes a needless and anxiety-arousing step.

Large core breast biopsies

Large core breast biopsy overcomes most failings of FNA and is increasingly popular, avoiding the need for surgical tissue sampling. Core biopsies are done in the imaging/radiology department, under ultrasound or mammographic (X-ray) guidance. Using large (14 gauge) needles, several cores of tissue are removed for examination. Core biopsy overcomes many disadvantages of fine needle aspiration, providing enough tissue for accurate evaluation. Taking several cores reduces the risk of false negative results.

If X-ray (stereotactic) guidance is used, the woman lies face down, her breast protruding through a hole in the table. With ultrasound guidance, she lies on her back during the procedure. If the lump is palpable (can be felt), the clinician inserts the needle into the right spot. If not, imaging devices (X-rays or ultrasound) guide the needle to the suspicious area in the breast. A spring-loaded device or “gun” is often used to insert the biopsy needle into the breast, quickly (and painlessly) removing cores of tissue from the target area.

The use of ultrasound or stereotactic (X-ray), guidance permits highly accurate location and removal of tissue from the suspicious area, giving samples large enough for histological examination, rather than the few cells obtained by FNA. The larger cores of tissue (about the size of mouse droppings) overcome the frequently indecisive results of FNA. Core biopsies are as accurate as surgical biopsies but quicker, simpler, cheaper, less disfiguring and less traumatic, also revealing the type and stage of the cancer. The core biopsy units can be attached to existing mammographic equipment (as “add ons”) or built into a special biopsy table. In the hands of radiologists skilled in imaging techniques, the accuracy of core biopsy equals that of traditional open surgery.

For a stereotactic core biopsy, the woman usually lies face down on the table, with her breast protruding through a special opening in the table. The recumbent position prevents fainting, which can happen if women sit for the procedure. The radiologist works out of sight, under the table – as if under a car – and digital computers help to calculate the location of the abnormality, giving a 3D or stereo image that pinpoints the suspicious area. The area to be examined is anaesthetized and a tiny nick made in the skin. The breast is compressed to permit accurate imaging. The biopsy device makes a small noise as it fires the needle, but the procedure is not usually painful – women say “it doesn’t hurt” or that “there’s no more discomfort than a prick, like having one’s ears pierced.” The main discomfort is some neck stiffness from lying on one’s stomach for half an hour or so.

Usually at least five tissue samples, sometimes more, are taken from various spots in the suspicious area. Whether ultrasound or X-ray imaging is chosen depends on the type of abnormality present, which imaging method provides the clearest picture and the equipment available. Some lesions (for example those in very dense breasts) are better visualized with ultrasound, while others show up best with X-rays. If both ultrasound and X-rays give equally good images, ultrasound is often the preferred guidance tool.

After the procedure, the woman gets up, has a steristrip over the biopsy site, exerts some pressure and perhaps an ice pack for a few minutes to stop bruising. Acetaminophen is taken to reduce pain if needed (not ASA as it increases bleeding). Normal activities can often be resumed the same day (but no very strenuous activities for about a week).

Core breast biopsies increasingly bypass the need for two breast cancer operations – one to obtain tissue samples for diagnosis, the second to remove the tumour and underarm lymph nodes (for testing). If the core biopsy reveals cancer, it is a nonsurgical diagnosis that gives the woman and her caregivers time to plan subsequent surgery and other treatment. The next step is usually lumpectomy to remove the tumour and also some axillary (underarm) nodes to test for malignant spread.

If the result is “no cancer,” the core biopsy has avoided the need for surgery. Women understandably feel immensely relieved if the core biopsy shows a benign condition for a mammographically suspect lesion, without the trauma and anxiety of a surgical operation. However, with some benign conditions (such as atypical ductal hyperplasia), surgical biopsy may still be advised to rule out concerns about early cancerous changes. If the core biopsy result is negative, women are advised to return for a repeat mammogram six months later to be sure nothing has changed.

Although core biopsy overrides the many disadvantages of FNA and is as accurate as surgical biopsy, it cannot be used in some situations, such as very deep breast lesions, in very small, thin breasts (too little tissue), or for women unable to lie comfortably on their stomachs for the required time.

Surgical “open” or formal biopsy of breast lumps

Surgical biopsies are excisional – if the lump is small and completely removed – or incisional, if a tumour is large and/ or very invasive, when a small piece may be removed for examination (hardly done any more). The procedure is similar for both types of surgical biopsy.

Excisional biopsy is usually suggested if the breast lump is small and can be clinically felt by hand, removing it completely for examination. If it turns out to be malignant, further surgery may be required to remove the rim or “margins” of tissue around the tumour to make sure the entire cancerous part is eliminated, perhaps also removing some underarm lymph nodes.

An incisional biopsy may still (rarely) be done to remove a piece for examination, for example with large lumps. “We try not to remove too much,” explains one surgeon, “because if it’s benign – as it is in the vast majority of cases – we don’t want to leave a large scar or disfigure the breast.”

Surgical biopsies are usually performed in hospital as “same day” procedures or in outpatient clinics, and the woman generally goes home the same day. The operation can be done under local or general anaesthesia, depending on the extent of surgery needed and the surgeon’s and woman’s preference. The type of anaesthesia – as well as the type of biopsy – is generally determined by the size and location of the abnormality. Before the biopsy, women can ask what anaesthetic will be used, discuss the type of operation and possible follow-up options so they understand and are comfortable with the plan.

For lumps that are small, well defined and near the breast surface, the surgeon might use local anaesthesia, injected near the surgery site. (Local anaesthesia night also be used after the incision is closed to lessen post-operative discomfort.) General anaesthesia will be used for larger excisions. After the operation and a few hours rest, the woman can usually go home, accompanied by a relative or friend (as people often feel groggy after anaesthesia).

Fine-wire localization aids surgical breast biopsy

The sophistication of modem mammography alerts clinicians to the presence of abnormalities or lumps too small to be felt. For such small lesions, an excisional biopsy is often done with the help of fine-wire localization, a technique in which the radiologist pinpoints the exact area to be biopsied. Fine wire localization is especially useful when mammography reveals the presence of tiny microcalcifications, scattered specks of calcium, that may indicate early breast cancer. (But microcalcifications rarely herald cancer unless clustered in one area of the breast.) However, even though they are mostly harmless, microcalcifications are usually investigated by biopsy – especially if they have emerged since the last mammogram.

In fact, the investigation of microcalcifications is a common reason for breast biopsies. “The problem with such biopsies,” states one breast specialist, “is that although the microcalcifications are picked up by the mammogram, we are not necessarily able to see them during surgery and night take out too large a section of breast tissue. Fine-wire localization is a great help in these circumstances.”

In a fine-wire localization, a needle is inserted into the breast with its tip near the abnormality. The radiologist then feeds in a wire no thicker than a hair, with a tiny hook at its end that fixes it in place to mark the suspicious spot for the surgeon. In practice, the woman is taken to the radiology department just before surgery and, under X-ray or ultrasound guidance, the radiologist inserts the needle and threads in the guide-wire. Fine-wire localization may sound painful, but once the needle penetrates the breast, insertion of the wire is surprisingly painless. In some centres, injecting dye into the suspicious spot is used to guide the surgeon.

Three ways to do breast biopsies

1. Fine needle aspiration known as FNA or FNAB (fine needle aspiration biopsy), a procedure that takes only a few minutes, using a fine needle to withdraw cells from the suspicious area for cytological examination (of single cells). If the abnormality can be felt, FNA is done in the surgeon’s office. If not, it is performed under ultrasound or occasionally X-ray guidance in the imaging or radiology department.

2 Large core breast biopsy, done by radiologists, uses a large core needle in a spring-loaded device under stereotactic (X-ray) or ultrasound guidance, to remove “cores” or plugs of tissue from the suspicious area for histological examination.

3. Open or “formal” (surgical) biopsy, the traditional method, is done by surgeons, with or without fine-wire X-ray localization (to pinpoint the area to be sampled). Surgical biopsies are excisional (removing the entire lump) or – less and less often – incisional (removing part of it).

Some pros and cons of the newer core biopsies

The chief advantages of core biopsy

* Non-invasive, quick and painless, providing larger specimens than FNA. * Less costly than surgical biopsy, avoiding the need for general anaesthesia, with no scarring to hinder interpretation of future mammograms. * Analysis of the cores may be sufficient to type and stage the cancer, providing information about its grade, hormone-receptors and other prognostic markers, also distinguishing localized (in situ) from invasive cancer. * The information obtained may be sufficient to plan surgical and follow-up treatment – e.g., merits of lumpectomy versus mastectomy, whether the underarm nodes will be removed at the time of surgery, whether radiation or chemotherapy will be required and in what order. * It can also identify benign abnormalities such as fibroadenoma, hyperplasia (tissue overgrowth) or hyperplasia with atypia (a possible warning sign for future breast cancer). * As accurate in diagnosing cancer as surgical biopsy. * High quality tissue plugs permit a full histological work up by the pathologist – avoiding the inconclusive results of FNA.

The limitations of core biopsy

* Although the samples are larger than those obtained with FNA, they are still quite small and if no cancer is found, surgical biopsy might still be needed. * Core biopsy units are not yet widely available. * Not suitable for lesions very close to the nipple, near the chest wall, in the armpit or close to the skin surface.

Awaiting the pathology report

The complete pathology report can take up to a week to prepare – a wait that can seem interminable – but the dull report is crucial for deciding the best treatment, It’s a period that takes considerable patience and requires much sympathy and support for the woman who is awaiting the results. Diagnosis of any cancer evokes chilling anxiety, but a diagnosis of breast cancer delivers a double blow to women. Not only does it signal the presence of a potentially lethal disease, but it also strikes at a woman’s self-image, sense of femininity and sex appeal. Women deserve all the attention and understanding they can get at this time.

COPYRIGHT 1995 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group