Clinical Presentation,Examination of Breast & Axilla,Diagnostic

Workup

By-Dr Satyajeet Rath

Topics covered• Introduction• Chief Complaints• Personal , Past & Family History• Examination of Breast

• Inspection• Palplation

• Examination of Axilla• Diagnostic work up

• Imaging studies• Pathologic studies

Introduction• The majority of patients with early breast cancers present

with a painless or slightly tender breast mass or have an abnormal screening mammogram

• Depending on tumor size, method of detection, and pathologic factors associated with the primary tumor, up to 30% to 40% of women with a clinically negative axilla may harbor subclinical pathologically involved axillary nodes.

Assessing the Breast

• Obtain a proper history• Perform a physical assessment• Imaging Studies• Pathological studies

Chief Complaints

Symptoms

• Painless Breast lump – Most common• Pain • Nipple discharge• Retraction of nipple• Swelling in axilla• Neck swelling

• Bony tenderness• Abdominal distension• Abdominal mass• Disturbed cognitive function

Painless breast lump- most common mode of presentation

• Enquire about :• onset, duration, rate of growth, change in size with menstruation.• most of the breast masses of Ca Breast are painless to begin with , they

may be painful in cases of Inflammatory ca or LABC• Associated with pain or other signs of inflammation

• Carcinoma breast• Painless to begin with except inflammatory Ca Breast

• May become painful in advanced stages• rapid growth & short history• Site: anywhere including axillary tail but mc in upper outer quadrant• Skeletal pain due to bony metastasis.• Neuronal pain due to brachial plexus involvement

Nipple Changes

1. Discharhge• Blood : duct papilloma or carcinoma• Pus : inflammatory carcinoma

2.Deviation of Nipple : • In carcinoma breast nipples

move towards the lump

a retracted nipple appears flat & broad

an inverted nipple can be pulled out

3.Destruction of nipples : • Nipples may be destroyed by

fungating breast carcinoma.

LYMPHADENOPATHY

Symptoms related to distant metastases

• Localizing neurologic signs• Altered cognitive function.

• Breathing difficulties • Abdominal distension • Jaundice• Bone pain

PERSONAL, PAST & FAMILY HISTORY

What can the personal history tell you….enquire about the following risk factor

• Gender : female (1% males)

• Race : more common in whites

• Age : increases as a woman gets older. • Relative : (mother or sister)• Menstrual history : early menarche , late menopause

• Childbirth : first child after the age of 30 or having no children at all

Pregnancy and breastfeeding are protective against breast cancer

• Obesity• Diet: Fat ,Alcohol

• Lack of Physical Activity , Stress• Radiation Exposure• History of cancer: breast, uterus, cervix, ovary

• Hormones: estrogens in Hormone replacement therapy & Birth control pills

> 70% have no risk factors

Contd.

Examination of the Breast

- Breast Self examination- Clinical breast Examination

When to do BSE• Menstruating women- 5 to 7 days

after the beginning of menses

• Menopausal women - same date each month

• Pregnant women – same date each month

• Perform BSE at least once a month

Breast Self Examination (BSE)

Breast Self Examination (BSE)• Monthly examination• May discover any changes early

Step 1: Begin by looking at your breasts in the mirror with your arms on your hips.

Step 2: Now, raise your arms and look for the same changes. 

Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood).

Breast Self Examination (BSE)

Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast

Step 5: Finally, feel your breasts while you are standing or sitting. Remember to cover the entire breast.

Breast Self Examination (BSE)

• However, the role of BSE is controversial.

• USPSTF recommends against teaching Breast Self Examination.

• NCI notes that it increases the number of diagnostic procedures without affording any mortality benefit.

- Baxter N. CMAJ, 2001.- Humphrey LL et al. Ann Intern Med 137, 2002- Thomas et al. J Natl Cancer Inst 94 (19), 2002.

Clinical Breast Examination

• Performed by doctor or trained practitioner

• Annually for women over 40yrs

• At least every 3 years for women between 20 and 40 yrs

• More frequent examination for high risk patients

Clinical breast examination

• Inspection: Palpation

• Lymph node examination• Examination to rule out metastasis

• expose up to waist• maintain privacy

Inspection: various positions & their importance

Sitting, arms at sides of body:

Most common position for examination of breastAdvantages:

Gives information regarding• Symmetry of breast• Skin & nipple changes• level of nipples,• breast lump • aids in palpation of axilla & scf

Disadvantages:• makes the breast look pendulous and bulky

Recumbent position

2nd most common position for examination of breast

Advantages: to palpate the breast against chest wall

• Palpate the lump • see its mobility • check for fixity with chest wall

Disadvantages:• Flatten the breast• Breast fall sideways

Arms pressing on hips

• This maneuver taut the

pectoral muscles. Helps to

see the fixity of lump to

underlying muscles and chest

wall.

Arms overhead

• Arms raised straight above head

makes the lump or dimple more

marked.

Leaning forward position

• Gives information regarding retraction of nipple if any

• When pt bend forwards the breast fall away, any failure of one nipple to fall away from chest indicate abnormal fibrosis behind nipple

ON INSPECTION OF BREASTLook for:•Breast :•Position, Size & shape •puckering, dimpling, retraction of skin over breast•Swelling, ulcer,fungation,nodules over breast

•Nipples: •Presence, position ,number, size & shape, prominence, flattened or retracted,•Look at surface of nipple for cracks, fissure or eczema•Nipple discharge

Skin over breast: color ,texture, engorged veins, Peau d’ orange

Areola: color, size, surface, montgomery’s tubercles

Fungated carcinoma in breast with axillary lymphadenopathy

Click icon to add picture

On inspection

Note the retraction of left nipple due to presence of carcinoma in upper outer quadrant ;swelling seen

Palpation: sitting position

• Confirm the diagnosis of inspection.

• Palpate the normal breast first.• Then the affected side is

palpated keeping in mind the findings of normal breast & comparing them

• The four quadrants should be palpated systematically.

Palpation :supine position

• Palpate a rectangular area extending

•vertically: from clavicle to the inframammary fold •laterally:from the midsternal line to the posterior axillary line• finally into the axilla for the tail of the breast.

• Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the fingers flat. It is important to be systematic.

Technique of palpation• Palpate the breasts using one of the three different patterns• circular or clockwise,• wedge, • vertical strip.

Levels of palpation

• Vary the level of pressure

• LIGHT – superficial

• MEDIUM – mid-level tissue

• Deep – to the ribs

Bimanual palpation

PALPATION FOR THE NIPPLES

PALPATION FOR THE NIPPLES: press the areola to see any discharge

• Bloody discharge is seen in papilloma & breast carcinoma

PALPATION FOR THE LUMPECTOMY OR MASTECTOMY SITE

• Mastectomy or lumpectomy scar

• Lymphedema• Signs of inflammation

What if we find a lump in the breast?

• Look for-• Local temperature• Tendernes• quadrant location • Number• Size & shape• Surface &Margin• Consistency:cystic.firm,

hard,stony hard• fluctuation

• Look for mobility or fixity of lump-

• Fixity to skin• Fixity to breast tissue• Fixity to pectoral fascia

&mucle• Fixity to chest wall

Fixity to skin can be tested in following ways:

• move the tumor side to side or up down:• if the tumor is fixed it may result in dimpling or tethering

of skin-skin is not able to slide over tumor.-skin over the tumor

• cannot be pinched up.-peau d’orange

• become more prominent

Difference between tethered & fixed breast lump

TETHERED FIXED

Means malignant disease has spread to fine fibrous

septa that pass from breast to skin

Means there is direct & continuous infiltration of

skin by tumor

Test for fixity of breast lump to pectoralis muscle

• Pt. is asked to press her hips.

• This taut the pectoralis muscle.

• Now the lump is moved in the direction of fibers of pectoralis major ms. & then at right angle

• Compare the range of mobillity

Feel the ant fold of axila to see that muscle is taut.

• Any restriction in mobility indicates fixation to pectoral fascia & muscle

• If the lump is fixed there will be no movement along the line of ms. Fiber but slight movement at right angle

• Fixity to breast tissue• Hold the breast tissue in one

hand & gently move the tumor with other hand.

• Asses the mobility of tumor• Fixed to breast• Cannot be moved

• Fixity to chest wall

• If the tumor is fixed irrespective of contraction of any muscle: it is fixed to chest wall

Examination of arms & thorax“Cancer en cuirasse”-

Multiple cancerous nodules and thickening infiltrate skin like a coat of armor may be seen in the arm & thoracic wall

Peau d’ orange: classic sign of carcinoma breast : This is due to blockage of subcuticular lymphatic's with edema of skin which deepens the mouth of sweat gland & hair follicles giving an orange peel appearance

Features of malignant mass• Hard• Painless• Irregular• Possibly fixed to skin or chest wall• Skin dimpling• Nipple retraction• Bloody discharge• Peau d orange

Brawny edema of arm due to extensive neoplastic infiltration of axillary Lymph node

Breast cancer presenting with unilateral enlargement of the nipple in a middle aged woman

Paget’s disease: Ulcerated nipple in a middle aged woman

Lymph node examination

• Very important for the staging & prognosis of breast cancer

• Done in sitting position.• The axillary & cervical group of lymph nodes are palpated

Lymph Node Examination

• abnormal nodes, described in terms of

• location • size • discrete or matted together• mobile or fixed • consistency (soft, hard,

firm) • tenderness

Characters of L.N enlargement in malignancy

• Slowly progressive,• firm, • Multiple nodes

involved, • stuck together &• to underlying

structures, • non tender.

Axillary LN examination

• Axillary lymph node groups

• Pectoral group• Brachial group• Subscapular group• Central group• Apical group

S Das,Manual of Clinical Surgery,Examination of Breast,10th Edition,

PECTORAL NODES

Method of palpation :The pt arm is elevated & using the right hand for left side the fingers insinuated behind pectoralis majorThe arm is now lowered and made to rest on clinicians forearm ( this relaxes P.minor )With pulp of finger palpate LN ,the palm faces forward.The thumb of same hand pushes the pectoralis major backwards from front (facilitates palpation)

Location; situated just behind the anterior axillary fold along the lateral thoracic vein.

• Arm is adducted & allowed to rest comfortably on clinician’s forearm

• The thumb pushes the p.major muscle backwards.Palm should look forward.

BRACHIAL GROUP• Location: It lies on lateral wall of

axilla in relation to axillary vein.• Method of palpation: • left hand is used for left side• It is felt with fingers and palm

directed laterally against the head of the humerus.

SUB-SCAPULAR NODESLocation: lies on posterior axillary fold in relation to subscapular vessels.Method of palpation:• stand behind the pt.• Hold the antero-internal

surface of post axillary fold with one hand

• While with other hand pt.arm is semi lifted

• The nodes are palpated along antero-internal surface of posterior axillary fold with palm of examining hand looking backwards

Contd.

CENTRAL NODES • Method of palpation:

• Pt. right central nodes examined with left hand.

• Pt.arm abducted & forearm rest on clinicians forearm

• Clinician passes his extended fingers right up to apex of axilla directing palm towards lateral thoracic wall

• Other hand of clinician placed on shoulder.

• Palpation carried by sliding fingers against chest wall.

APICAL NODES

Method of Palpation: same as central group nodes but fingers

are pushed further upIf the lymph nodes are very much enlarged

they may push themselves through the clavi-pectoral fascia& the pectoralis major muscle just below clavicle

Palpation of SUPRACLAVICULAR L.N

• the clinician stands behind the patient & dips the finger down behind the middle of clavicle.

• Two sides may be palpated simultaneously & compared

• Passive elevation of shoulders would relax the muscles of neck & facilitate palpation

• Always flex the neck of patient for better palpation

Palpation of supra clavicular node

GENERAL EXAMINATION

• Look for signs of liver secondaries:

• hepatomegaly • Ascitis with jaundice• Tenderness in right

hypochondrium

Per abdomen examination

Examination of liver

• EXAMINATION OF BONES FOR SKELETAL METASTASIS: evaluation of site of bone pain

• NEUROLOGICAL EXAMINATION FOR BRAIN METASTASIS

• RECTAL & VAGINAL EXAMINATION TO DETECT KRUKENBERG’S TUMOUR OF OVARY (which occur by trans celomic spread or lymphatic spread)

GENERAL EXAMINATION: to determine metastasis

• AUSCULTATION OF LUNG FOR PULMONARY METASTASIS

Diagnostic Work Up for Ca Breast :-

• General * History with emphasis on presenting symptoms, menstrual status, parity, family history of cancer, other risk factors *Physical examination with emphasis on breast, axilla, supraclavicular area, abdomenSpecial tests *Biopsy (core biopsy directed by physical examination, ultrasound, or mammography as indicated, or needle localization)Radiologic studies Before biopsy *Mammography/ultrasonography *Chest radiographs *Magnetic resonance imaging of breast (selected cases)

Perez & Brady’s,6th edition

After positive biopsy *Bone scan (when clinically indicated, for stage II or III disease or elevated serum alkaline phosphatase levels) *Computed tomography of chest, abdomen and pelvis for stage II or III disease and/or abnormal liver function testsLaboratory studies *Complete blood cell count, blood chemistry *UrinalysisOther studies *Hormone receptor status (ER, PR) *HER2/neu status *Consider genetic counselling/BRCA testing in selected cases

Perez & Brady’s,6th edition

Contd.

Diagnosis• Imaging Studies• Pathologic Studies

Imaging in Breast Canceer diagnostic and Work up• Mammography• Ultrasound• MRI• Bone Scans• PET Scan• CT• Image guided – Stereotactic,USG guided

Perez & Brady’s,6th edition

Mammography• Mammography remains the most critical

component of diagnostic imaging in breast cancer patients.

• Bilateral mammograms should be performed routinely in the work-up of the breast cancer patient.

Mammography• MLO View – • breast is compressed along

a plane of approx. extending from upper inner quadrant to lower outer quadrant

• includes tissues from axillary tail of spence to abdominal wall

CC View – • breast is positioned on

the x ray cassette holder • compression is applied

from above • laterally exaggerated CC

view are needed in 11% women to fully evaluate lateral aspect

• Screening Mammography - evaluation of asymptomatic women to detect unsuspected Ca Breast

• Diagnostic Mammography –definitive imaging work up

• Following breast conservation most patients will undergo diagnostic mammograms, as additional images are often needed to rule out suspicious findings in the previously radiated breast.

BI-RADS (ACR)• Breast Imaging Reporting And Data System• Category 0 – incomplete assessment,need

additional imaging evaluation• Category 1 – breast normal , no malignancy• Category 2 - benign (a benign finding present)• Category 3 – probably benign• Category 4 – suspicious abnormality , possibility of

being malignant , biopsy should be considered• Category 5 – highly s/o malignancy• Category 6 – biopsy proven

Malignancy Characteristics in Mammography: • Irregularity of shape• Irregular margin• Indistinct / ill defined margin• Spiculated mass – projections extending radially

from tumour mass that contain cancer cells and fibrous tissue

• Greater radiographic density than fibroglandular tissue

Architectural DistortionAsymmetry

Malignant masses have more speculated appearance

• Classically, breast carcinoma is seen as an ill-defined mass that may have spiculated margins

• Although rarely cancers may also be seen with a knobby, lobulated, or even a smooth contour

• Architectural distortion of the breast tissue • Appearance of linear, radiated, or spiculated changes

around a central focus should always be considered suspect for carcinoma.

• If microcalcifications were initially present, radiographs of the surgical specimen and postlumpectomy mammography are important to rule out residual disease for patients considering breast-conservation therapy

• Calcifications associated with malignant tumors• typically 100 to 300 µm in size • rodlike, tubular, branching, or punctate. • Clusters of microcalcifications (more than 5) are

suggestive of intraductal disease, (and in nonpalpable lesions needle localization aids in the diagnosis)

• For patients undergoing biopsy of a suspicious mass or calcifications , about 30% will yield a diagnosis of malignancy.1

• average sensitivity is approx. 90% (60% - 95%)• specificity is 94% (50-98%)• positive predictive value is approx. 8%- 14% for screened

patients• but is significantly higher for patients with symptoms or

palpable masses

2.Perez & Brady’s,6th Edition

1.Harris J, Lippman M, Morrow M, et al. Diseases of the breast. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2004

USG• Useful tool to complement physical examination and

mammography• Use as screening tool is limited• Reported sensitivity of 73 % and specificity of 95 %• Very helpful in differentiating cysts from solid tumors• Primary use -- identification and characterization of

palpable and non palpable abnormalities of breast detected by physical examination and mammography.

Perez & Brady’s,6th Edition

USG• Suspicious of malignancy

when we have these findings

• Irregular internal echoes• Hypoechoeic mass• Spiculation• Width that does not exceed

the height• Shadowing• Posterior

enhancement/halo• Disruption of tissue planes

Donegan & Spratt,Cancer of the Breast,5th edition,Diagnosis of Ca Breast,Pg-332

• Soo et al.1 – in evaluation of 420 patients , reported the negative predictive value > 99% if both mammography and ultrasonography are negative.

• Particularly useful in young women with dense breasts in whom mammogram are difficult to interpret.

• In addition to complementing physical examination and mammography, USG is often used as a guide for interventional procedures.

• USG Guided core biopsies are routinely performed in the diagnosis of breast cancer.

• Can also be used for FNABs , presurgical localizations

2.Perez & Brady’s,6th edition

1.Soo MS, Rosen EL, Baker JA, et al. AJR Am J Roentgenol 2001

MRI• Use of MRI to supplement mammography in breast

cancer diagnosis and treatment is rapidly increasing• In a review of MRI in the management of breast

cancer, Hylton 1 summarized the potential for the current use of MRI:

• to complement mammography in screening; • for differential diagnosis of questionable findings on

physical examination, mammography, and ultrasound; and

• assessment of response in the neoadjuvant treatment of breast cancers.

2.Perez & Brady’s,6th edition

1. Hylton N. J Clin Oncol 2005

• The NCCN recommends breast MRI for those• women with early-stage disease whose breasts can’t be imaged

adequately by mammography and ultrasound,• those women who receive neoadjuvant chemotherapy to assess

response to occult breast cancer, or • with genetic mutations leading to a higher risk of bilateral or

contralateral breast cancer

• MRI has a clear role in the evaluation of patients • who present with axillary metastasis with no evidence of a primary

tumor in the breast by physical examination or mammography.

• Esserman et al[1] reported that MRI was more sensitive and • MRI successfully detected cancer in 55/58 cases. • The anatomic extent of disease was correctly identified in

98% of cases by MRI but in only 55% by mammography.

1.Esserman L, Hylton N, Yassa L, et al. J Clin Oncol 19992.Buchanan CL, Morris EA, Dorn PL, et al. Ann Surg Oncol 2005

• In an analysis from Memorial Sloan-Kettering Cancer Center, Buchanan et al.2 reported on –• 55 patients who presented with axillary adenopathy

without evidence of distant disease. • The authors concluded that breast MRI detects

mammographically occult cancer in half of women with axillary metastases and is a valuable tool for patients with occult primary breast cancer.

Summarising MRI

• A breast MRI is not a replacement for mammography for high risk women.

• Instead, it should be used as a complementary screening tool. • This is because although an MRI may be more likely to find

cancer than mammography, it often misses some cancers that mammography easily detects.

• For women with an average risk of breast cancer, mammography is still the standard method for diagnosing early-stage breast cancer.

CT• There is no established role for CT scans in routine staging of

patients with early stage breast cancer.• Most patients with node-negative breast cancer do not need

to undergo routine CT scans for staging, since the yield is exceeding low.

• A small percentage of women with very high-risk node-negative disease or with node-positive disease may be upstaged by routine CT scans and, although the yield is low, it is common practice to CT stage high-risk node-negative and node-positive breast cancer patients.

• Many women undergoing breast-conserving surgery and radiation do have CT scans as part of radiation therapy treatment planning.

• NCCN Guidelines on Breast cancer • recommend an Abdominopelvic CT if abnormal Lab

values or physical examination are present or if the patient is deemed as a stage IIIA(T3N1M0) or greater.

• If any neurologic symptoms suggestive of cerebral metastases are present, a contrast-enhanced CT scan or gadolinium-enhanced magnetic resonance imaging (MRI) scan of the brain should be obtained.

• Gadolinium-enhanced MRI is the preferred imaging technique if leptomeningeal carcinomatosis is suspected.

Bone Scans• Routine bone scan at the time of initial treatment of stage I and

II breast cancer is of limited value• Reserved for patients with bone pain• the incidence of abnormalities on bone scan in

• patients with stage I disease is approximately 2%, • but a greater incidence of abnormalities is found in stages II (10%)

and III (>20%)• Koizumi et al. 1 reviewed records from 5,538 patients with

breast cancer. • The overall incidence of metastasis to bone was 2.13% (0% in

patients with stage 0,• 0.08% in stage I, • 1.09% in stage II,• 9.96% in stage III, and• 34.04% in stage IV.

1.Koizumi M, Yoshimoto M, Kasumi F, et al. Jpn J Clin Oncol 2001

• Bone scans are more commonly recommended in • patients with stage II larger tumors (>3 cm), • aggressive histopathologic features, and• in stage III or IV cancer.

• Bone scans are recommended for all patients with locally advanced disease; up to 35% of patients with clinical stage III cancer can show abnormal bone scan results

PET Scanning• PET using 18F-labeled fluorodeoxyglucose (FDG) scanning,

• not a routine component of staging,• being used more frequently in breast cancer.

• Its application in patients on initial presentation with early stage disease has not been established.

• However, its potential role in patients with metastatic, advanced, and local &regional relapse of disease is rapidly evolving.

• The NCCN Guidelines• recommend against routine PET Scans in patients with stage 0 to IIIA

disease • But does state that it may be useful in patients with locally advanced

disease or in situations where standard imaging results are equivocal or suspicious.

• Weir et al. 1 analysed PET Scans of 165 patients • concluded that there are two clinical situations in which PET

appears to be particularly valuable1. evaluation of patients who are suspected of having a tumor

recurrence2. in identifying patients with multifocal or distant sites of

malignancy who otherwise appear to have an isolated, potentially curable, local & regional recurrence

• In another study 2 it was concluded that • In detecting multifocal lesions, FDG PET was twice as sensitive (63%)

as the combination of mammography and ultrasonography (32%).• But because FDG PET had a false-negative rate of 20% for detection

of lymph node metastases, this imaging method cannot replace histologic evaluation of axillary nodes

1.Weir L, Worsley D, Bernstein V. Breast J 20052. Schirrmeister H, Kuhn T, Guhlmann A, et al. Eur J Nucl Med 2001

Summary of Imaging studies• All women should undergo history and physical examination, with

mammography and liver function tests. • Ultrasound and/or MRI may be useful in selected cases to

complement mammography. • For women who have operable disease with normal liver function

tests, surgical staging of the breast and node sampling is performed.• For low-risk patients, no further staging is required.• For women with more advanced disease and those being

considered for neoadjuvant chemotherapy, preoperative staging would routinely include a bone scan, chest x-ray and CT, and/or abdominal ultrasound.

• PET scanning may be considered in selected cases.

Perez & Brady’s,6th edition

TRIPLE DIAGNOSIS• The combination of Mammography , physical

examination and FNAC , referred to as TRIPLE DIAGNOSIS.

• More reliable than each of these alone in evaluating a breast mass

• In one report , sensitivities of 84%,86.7% & 79.1% were found for each respectively,versus,99.2% for triple diagnosis.

• When the results of all three tests indicate malignancy,open biopsies confirm cancer in 99.4% to 100% cases.

Drew PJ,Standard Triple Assessment,Ann Surg. 1999

Pathologic Studies• Histo-pathologic diagnosis may be obtained by fine-needle aspiration of

cystic or solid masses or biopsies of solid masses; • any fluid aspirated from the breast should be examined for malignant cells. • Fine-needle aspiration of the breast is a

• simple, • low-cost, • accurate diagnostic technique

• A potential limitation of fine-needle aspiration is that it provides cytology and no tissue architecture.

• Therefore, while the presences of malignant cells can be detected, cytology from fine-needle aspiration cannot conclusively differentiate invasive from non-invasive disease.

• However, for lesions that are palpable or easily visualized on ultrasound, this method results in rapid and efficient diagnosis.

The presence or absence of carcinoma in a suspicious clinically or mammographically detected abnormality can only be reliably determined by tissue sampling.

• The presence or absence of carcinoma in a suspicious clinically or mammographically detected abnormality can only be reliably determined by tissue sampling.

• A biopsy remains the standard technique for diagnosing both palpable and nonpalpable breast abnormalities.

• The available biopsy techniques for the diagnosis of palpable breast masses are

• fine needle aspiration (FNA), • core cutting needle biopsy, and• excisional biopsy.

DeVita,Lawrence,Rosenberg Oncology,9Th Edition,Pg-1407

Biopsy: positive result is diagnostic

1. Excision biopsy2. Incision biopsy3. True-cut or core biopsy

(Vim-Silverman)4. Fine needle biopsy

o Breast biopsy of any suspicious mass is mandatory.

Fine needle aspiration biopsy

• If the lump can't be felt easily, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass.

• An FNA biopsy is the easiest type of biopsy to have, but it has some disadvantages.

• It can sometimes miss a cancer if the needle is not placed among the cancer cells.

• And even if cancer cells are found, it is usually not possible to determine if the cancer is invasive.

Core needle biopsy

• A core biopsy uses a larger needle to sample breast changes felt by the doctor or pinpointed by ultrasound or mammogram.

• When mammograms taken from different angles are used to pinpoint the biopsy site, this is known as a stereotactic core needle biopsy.

• The needle used in core biopsies is larger than the one used in FNA.

• It removes a small cylinder (core) of tissue (about 1/16- to 1/8-inch in diameter and ½-inch long) from a breast abnormality.

• Several cores are often removed. • The biopsy is done using local

anesthesia (you are awake but the area is numbed) in an outpatient setting.

Surgical (open) biopsy• Usually, breast cancer can be diagnosed using needle biopsy.

Rarely, surgery is needed to remove all or part of the lump for microscopic examination.

• This is referred to as a surgical biopsy or an open biopsy.• Most often, the surgeon removes the entire mass or abnormal

area as well as a surrounding margin of normal-appearing breast tissue. This is called an excisional biopsy.

• If the mass is too large to be removed easily, only part of it may be removed. This is called an incisional biopsy.

• A surgical biopsy is more involved than an FNA biopsy or a core needle biopsy. It typically requires several stitches and may leave a scar.

• Core needle biopsy is usually enough to make a diagnosis, but sometimes an open biopsy may be needed depending on where the lesion is, or if a core biopsy is not conclusive.

DeVita,Lawrence,Rosenberg Oncology,9Th Edition,Pg-1407

Receptor Status• ER and progesterone receptor (PR) assays are routinely done .• These parameters are correlated with prognosis and tumor

response to chemotherapeutic and hormonal agents .

• HER-2/neu assay is being done routinely because overexpression is associated with poor prognosis, and these patients are currently being offered adjuvant therapy directed at HER2/neu.

• HER2/neu analysis by fluorescent in situ hybridization techniques has recently evolved as the standard for determining response to therapy directed at the HER2/neu oncogene . 1

Perez EA, Suman VJ, Davidson NE, et al. J Clin Oncol 2006

THANK YOU