We now have available several minimally-invasive diagnostic options. An attempt is made to select the option that is the least invasive and the best tolerated by the patient. In most instances, the diagnosis can be made in the office on the patient’s first visit.
In some situations, an open surgical biopsy is still required to establish an accurate diagnosis. Procedures used at the Center include the following:
- Fine Needle Aspiration
- Core Needle Biopsy
- Stereotactic Core Biopsy
Fine Needle Aspiration
The original, minimally-invasive procedure for diagnosing breast cancer was the use of a fine needle aspiration biopsy. This technique has been used for over 50 years and has proven to be highly valuable in situations where expert pathologists are available to interpret the aspirated specimen. We have performed over 5,000 of these aspirations at The Breast Care Center with excellent results.
The techniques of this procedure are rather simple. A very fine needle is inserted into the tumor. In some cases where the tumor is not palpable, an ultrasound is used to guide the needle to the area of concern. The needle is moved back and forth and placed on a slight suction so that cells can be removed from the tumor. These cells are placed on a slide and evaluated by the pathologist. In our experience, 80% of palpable tumors can be diagnosed using this technique. It is usually performed at the time of the patient’s first office visit. The results are often available within two hours. In cases where this procedure does not give a precise diagnosis, the next step is usually a core needle biopsy.
Core Needle Biopsy
The core needle removes a sliver of tissue from the tumor (the biopsy specimen is approximately the diameter of the lead in a pencil). Because of the large sample size, a more detailed analysis can be performed. This allows the pathologist to comment on the tumor’s cell type and to differentiate between invasive and noninvasive cancer. The procedure is approximately 98% accurate in our hands and is used quite commonly when a fine needle aspiration has failed to give a specific diagnosis, or in cases where the added information is important in pretreatment planning.
This procedure requires local anesthesia and usually takes 20 minutes to perform. Again, this procedure is done in the office and results are available within 24 hours. In cases where this procedure does not give a precise diagnosis, an open biopsy is performed.
Stereotactic Core Biopsy
In situations where a suspicious lesion is identified on the mammogram, but is not palpable or visible on the ultrasound, the stereotactic technique is used to make the diagnosis. This procedure is performed by our mammographers. The patient lies down on a table with the breast protruding through a special opening. A mini-mobile mammogram unit is placed under the table. Films are taken of various angles, which allow a computer to construct a three-dimensional image. A needle is then directed to the area of concern and a core biopsy specimen is obtained. The results are usually available within 24 hours. This procedure requires local anesthesia, is relatively painless, and takes about 45 minutes.
The mammotome is a variation of the stereotactic technique in which a larger sample of tissue is obtained with the use of a specially designed suction device. This is currently the procedure of choice at The Breast Care Center and has proven to be remarkably successful in lesions seen on the mammogram.
Lymph Node Surgery
In the treatment of invasive cancer, whether a woman has a mastectomy or lumpectomy, she and her doctor usually need to know if the cancer has spread to the lymph nodes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.
Doctors once believed that removing as many lymph nodes as possible would reduce the risk of developing spread of breast cancer and improve a woman’s chance for long-term survival. We now know that removing the lymph nodes probably does not improve the chance for long-term survival. But knowing whether lymph nodes are involved is important in selecting the best treatment to prevent cancer recurrence.
The only way to accurately determine if lymph nodes are involved is to remove and examine them under the microscope. This means removing some or all of the lymph nodes in the armpit. In the standard operation, called an axillary lymph node dissection, all the lymph nodes are removed. This is often necessary. In many cases, lymph node testing may be done with a more limited surgery that only removes a few lymph nodes with fewer side effects. This is called sentinel lymph node biopsy, and is discussed further below.
For some women with invasive cancer, removing the underarm lymph nodes can be considered optional. This includes:
- Women with tumors so small and with such a favorable outlook that lymph node spread is unlikely
- Instances where it would not affect whether adjuvant treatment is given
- Elderly women
- Women with serious medical conditions
Lymph node surgery is not usually necessary with ductal carcinoma in situ or pure lobular carcinoma in situ. A sentinel node biopsy may be done if the woman is having surgery (such as mastectomy) that would make it impossible to do the sentinel node biopsy procedure if invasive cancer were found in the tissue removed during the surgery.
The surgical technique used to remove lymph nodes from under the armpit depends on the personal circumstances of the patient.
If there are enlarged lymph nodes with apparent spread of the cancer, or the lymph nodes are otherwise found to be involved with cancer, then complete axillary lymph dissection is necessary. However, in many cases, the lymph nodes are not enlarged and are not likely to contain cancer. In such cases, the more limited sentinel lymph node biopsy procedure can be performed.
In the sentinel lymph node biopsy procedure the surgeon finds and removes the “sentinel nodes”, the first few lymph nodes into which a tumor drains. These are the lymph nodes most likely to contain cancer cells. To find these so-called “sentinel lymph nodes”, the surgeon injects a radioactive substance and/or a blue dye under the nipple or into the area around the tumor. Lymphatic vessels carry these substances into the sentinel lymph nodes and provide the doctor with a “lymph node map”. The doctor can either see the blue dye or detect the radioactivity with a Geiger counter. The surgeon then removes the marked nodes for examination by the pathologist.
If the sentinel node contains cancer, the surgeon removes more lymph nodes in the armpit (axillary dissection). This may be done at the same time or several days after the original sentinel node biopsy. If the sentinel node is cancer-free, the patient will not need more lymph node surgery and can avoid the side effects of full lymph node surgery. This limited sampling of lymph nodes is not appropriate for some women. A sentinel lymph node biopsy should be considered only if there is a team experienced with this technique.
Lymph node removal will be recommended for most women with breast cancer. Lymph nodes are lima bean shaped structures that vary in size from that of a pea to the size of a marble. A primary function of a lymph node is to filter unwanted materials from the body, and this includes cancer cells. In fact, if breast cancer cells break off from the main tumor, the first place they are likely to go to the lymph nodes under the arm (i.e. the axillary lymph nodes). One of the most important indicators of prognosis is the status of the axillary lymph nodes (i.e. no nodes involved good means prognosis; the more nodes involved, the worse the prognosis). For this reason it was standard therapy in the past to remove all of the lymph nodes under the arm at the time of the removal of the breast cancer to determine prognosis.
Side Effects of Lymph Node Surgery
Side effects of lymph node surgery can be bothersome to many women. The side effects can occur with either the full axillary lymph node dissection or sentinel lymph node biopsy. Side effects are much less common and less severe with the sentinel lymph node procedure. Side effects of lymph node procedure:
- Temporary or permanent numbness in the skin on the inside of the upper arm
- Temporary limitation of arm and shoulder movements
- Swelling of the breast and arm called lymphedema
Lymphedema is the most significant of these side effects. If it develops it may be permanent. Most women who develop lymphedema find it bothersome but not disabling. No one can predict which patients will develop this condition or when it will develop. Lymphedema can develop just after surgery, or even months or years later. Significant lymphedema occurs in about 10% of women who have axillary lymph node dissection and in up to 5% of women who have sentinel lymph node biopsy.
With care, patients can take steps to help avoid lymphedema or at least keep it under control. Talk to your doctor for more details.
To reach cancer cells that may have spread beyond the breast and nearby tissues, doctors use drugs that can be given by pills or by injection. This type of treatment is called systemic therapy. Examples of systemic treatment include chemotherapy, hormone therapy, and monoclonal antibody therapy. Hormone therapy is only helpful if the tumor is hormone receptor positive.
Even in early stages of the disease, cancer cells can break away from the breast and spread through the bloodstream. These cells usually do not cause symptoms, they do not show up on an x-ray, and they cannot be felt during a physical examination. But if they are allowed to grow, they can establish new tumors in other places in the body. Systemic treatment given to patients who have no evidence of spread of cancer, but who are at risk of developing spread of the cancer is called adjuvant therapy. The goal of adjuvant therapy is to kill undetected cancer cells that have traveled from the breast.
Women who have invasive breast cancer should receive adjuvant therapy, except those with very small or well-differentiated tumors. In most cases, systemic treatment is given soon after surgery using the results of the surgery and pathology evaluation to determine the best choice treatment. In some cases, the systemic therapy is given to patients after a needle biopsy but before lumpectomy or mastectomy. This is called neoadjuvant treatment. Oncologists give patients neoadjuvant treatment to try to shrink the tumor enough to make surgical removal easier. This may allow women who would otherwise need mastectomy to have breast-conserving surgery.
For women whose breast cancer has spread to other organs in the body (metastases), systemic treatment is the main treatment. This treatment may be chemotherapy, hormone therapy, trastuzumab, or combined therapy.