INTRODUCTION
Mammography has stood the test of time and is considered the best screening tool for Breastcancer, and is the first line of investigation for most breast symptoms. As an investigative tool ithelps characterise breast lesions and thus plays a significant role in reducing mortality andmorbidity from breast cancer. Along with ultrasound, it continues to be the basic investigative tool for breast diseases. Even when Breast screening MRI study is performed, it is imperative that an accompanying Mammogram is performed.
TECHNIQUE
This goes a long way in acquiring images that are optimal and useful.Mammography should include Mediolateral oblique and Craniocaudal views of each breast. These are regarded as the Standard views. Even when symptoms are unilateral, bilateral Mammogramsare advised to assess asymmetric abnormalities. Digital mammography is preferred to film screenmammography, particularly for women aged < 50 years and for those with dense breast tissue. Other views such as the laterally and medially extended craniocaudal views, and the valley view help visualise areas of the breast that are difficult to visualise on the standard views.
INDICATION
Broadly the indications for Mammography fall into two categories :
Screening and Diagnostic.
Screening Mammograms: These are for ladies who have no breast symptoms and no clinical signs of breast cancer. The purpose is early detection of breast cancer, when it is small and impalpable. This is to aid reduction of patient morbidity and mortality.
Diagnostic Mammograms: These are for ladies who have a symptom such as a palpable lump orblood stained nipple discharge, etc. The mammograms are acquired to identify the cause of thesymptom, more specifically to diagnose if the symptoms are caused by a malignant mass.
COMMON BREAST SYMPTOMS
Common breast symptoms include breast lump, pain, nipple discharge, inflammation; either alone or in combination.
Breast imaging performed in this group of patients is called diagnostic breast imaging.
Purpose of clinical and imaging evaluation is to determine the cause of symptoms so that appropriate treatment can be given and secondly, to determine if the symptom is caused by underlying breast cancer.
Accordingly, evaluation of patient with any breast symptom should begin with detailed history and good clinical breast examination (CBE).
BREAST LUMP
Breast lump is the most common breast symptom. Although most breast lumps are benign, it is alsothe most worrisome complaint as it the most common presentation of a breast cancer.All patients presenting with breast lump should undergo Triple assessment . It is a combination ofclinical breast examination, imaging test and pathological test. It is a standard and accurate methodto diagnose breast cancer in symptomatic breast .
Imaging modality
Up to 30 years of age ultrasound of both breasts is the primary modality.Mammogram in this age group is performed only if there is strong clinical suspicion of breast cancer.If age is more than 30 years, then both mammography and ultrasound of both breasts arerecommended .
Further management is according to imaging results as follows
Simple cyst or Complicated cyst
with debris, thin septation etc (BIRADS 2)
No further imaging. Cyst may or may not be aspirated if not responsible for symptoms. If aspirated, fluid cytology is not required. No imaging follow-up is recommended.
Complex cyst
(having suspicious solid component) - image guided aspiration and core biopsy.However, excision of the cyst and histopathology is preferred.
Solid benign mass (BIRADS 3)
Imaging follow-up only. Ultrasound guided core biopsy if there is a high risk factor or clinical suspicion for cancer or already diagnosed cancer in same or contralateral breast.
Suspicious mass (BIRADS 4 or 5)
Image guided core biopsy.
Calcifications only
No further evaluation if typically benign. All calcifications which are not typically benign must be subjected to core biopsy. Specimen mammography of harvested cores is recommended to establish retrieval of calcification in harvested cores .
Biopsy results
For BIRADS 4 lesions, if biopsy result is benign, then follow-up ultrasound and mammogram after 6 months.
If biopsy result is malignant then appropriate treatment.
If biopsy result is inconclusive (equivocal or atypia) then re-biopsy, preferably vacuum assisted biopsy is recommended .
For BIRADS 5 lesions, re-biopsy is must if histopathology result is not malignant on initial biopsy.
Mass on Clinical Breast Examination (CBE) but negative imaging
Palpation guided biopsy.
No mass on CBE as well on imaging
No further imaging. Follow-up with CBE may be considered
BREAST PAIN (MASTALGIA) AND MASTITIS
Mastalgia alone is generally not a feature of breast cancer. It may be due to aberrant response of breast tissue to the hormonal variations, especially if it is cyclic, bilateral and associated with vague nodularity of the breast.
Other causes may include infection, trauma and some drugs(spironolactone, Digoxin, haloperidol etc).
Age of the patient, history and CBE will guide the imaging protocol.
No imaging is required if pain is bilateral or diffuse, cyclic and CBE is normal.
If breast pain or tenderness is focal or associated with mass, then imaging is required.
Imaging
Ultrasound only for age up to 30 years and both mammography and ultrasound for age more than 30 years .
Mammography should be avoided in lactating and highly painful breasts which preclude adequate compression during mammography. Ultrasound alone is sufficient in them.
An imaging protocol as outlined for breast lumps in preceding sections may be followed.
Acute mastitis is characterized by focal breast pain, inflammatory skin changes along with fever and malaise. It can be lactational or non-lactational. It is diagnosed clinically and managed conservatively with antibiotics.
Imaging is recommended only if mastitis is non-resolving or progressive.
Ultrasound is the modality of choice as mammography is difficult to perform and interpret in acute mastitis.
If mastitis has liquefied into an abscess formation, surgical or ultrasound guided drainage should be considered .
One or repeated aspiration with large bore needle is recommended. Indwelling catheter drainage is effective for large recurring abscess .
Follow-up mammography and ultrasound is recommended in non-lactational mastitis or abscess after acute symptoms have resolved.
A non-resolving lesion should be subjected to biopsy .
If inflammatory breast cancer is suspected, then ultrasound of both breasts and if possible,mammography should be performed . Image guided biopsy should be obtained if focal lesion is seen. If no focal lesion is seen, then Contrast Enhanced Magnetic Resonance Imaging (CEMRI) of both breasts should be performed to localize the primary tumor.
IMAGING IN COMMON BREAST COMPLAINTS
NIPPLE DISCHARGE
Usual causes include physiological, hormonal disorders, benign lesions like papilloma and duct ectasia and uncommonly, cancer.
Some drugs (M-Dopa, Cimetidine, reserpine, antipsychotics andoral contraceptives) can also cause nipple discharge.
Good CBE is initial step. Color of the discharge should be noted. Multiduct or expressable only clear,yellow, green, grey, black or white discharge indicates benign causes.
CBE should be performed and if negative, then assurance is adequate. Imaging is not required.
Serum prolactin levels and thyroid profile may be obtained if patient is not pregnant nor lactating and hormonal cause is suspected.
If infection is suspected, then antibiotics for one week and re-assessment with CBE are recommended.
Occasional bilateral bloody discharge in children is also self-limiting and no imaging is required.
Triple assessment is required in other patients.
Risk of breast cancer is high if nipple discharge is from single duct, spontaneous, serous or bloody, associated with lump on CBE or age is more than50 years .
Ultrasound only (age up to 30 years) and mammography with ultrasound (age more than 30 years) should be performed.
If abnormality is found on imaging, further management will depend on its BIRADS category.
If no abnormality is found and discharge is serous or bloody, CEMRIshould be obtained.
If clinical or imaging findings are suggestive of duct ectasia or periductal mastitis, culture sensitivity of duct discharge followed by appropriate antibiotics treatment should be considered .
If CBEand imaging are negative and discharge is persisting, surgical exploration (microdochectomy) shouldbe considered .
PATIENTS WITH OPEN, DISCHARGING OR ECZEMATOUSSKIN LESION
These include patients with chronic infection with sinus formation such as Tuberculosis, recent lumpectomy or trauma or those with locally advanced fungating cancers.
After history and CBE,initial imaging should be with bilateral breast ultrasound.
Mammography is difficult to perform in these patients. Further management will be guided by CBE and ultrasound findings.
In patients suspected to have breast cancer and no definite mass is found on CBE or ultrasound,CEMRI of breasts is recommended.
It is also recommended if cancer is already diagnosed on lumpectomy and breast conservation is being considered .
If patient has eczematous skin changes at or around nipple-areola, with or without duct discharge,dermatitis should be excluded first.
Other cause is Paget’s disease and hence CBE, mammography and ultrasound should be performed. If it is negative, CE-MRI of breast should be obtained.
Image guided biopsy of eczematous nipple or any suspicious lesion on imaging should be undertaken .
PATIENTS ALREADY DIAGNOSED WITH BREAST CANCER
Pre-operative breast imaging should include bilateral mammography and ultrasound. If additional lesion is seen on any of these imaging tests, further management depending on BIRADS category of the additional lesion is considered.
BIRADS 2 lesions can be ignored and surgery undertaken as per the plan. If additional lesion is BIRADS category 3,4 or 5, its image guided biopsy is ecommended.
Preoperative CEMRI of both breasts is not routinely recommended, however, can be considered as per the institutional policy. It is recommended in cases of lobular carcinoma, young women andthose with dense breasts (ACR-BIRADS density C or D) . It is also recommended if accelerated partial breast irradiation (APBI) is being considered. If additional suspicious lesion is seen on MRI and it can change the planned treatment, a biopsy of such lesion should be considered.
If patient with locally advanced breast cancer is considered for neo-adjuvant chemotherapy before surgery, then image guided core biopsy with complete histological analysis, tumor grade and ER,PER, HER2 receptor status should be obtained before initiation of chemotherapy. FNAC diagnosis only is not sufficient.
If breast conservation surgery is considered in such a patient and breast mass is devoid of calcifications, placement of radio-opaque marker clip in the tumor is highly recommended. This clip will help to localize the tumor in case of complete clinical and imaging resolution of the lesion after chemotherapy.
IMAGING FOR METASTATIC WORK-UP IN PATIENTSALREADY DIAGNOSED WITH BREAST CANCER
For early breast cancers (up to stage IIB - up to 5 cm with clinically absent or mobile axillary lymphadenopathy with no distant metastases), a chest x-ray is sufficient.
Ultrasound of abdomen and pelvis is recommended in these patients if liver function tests are abnormal.
MDP bone scan is recommended if serum alkaline phosphatase is elevated or if patient is symptomatic for metastaticsite .
For other breast cancers, following imaging is essential. Chest x-ray, ultrasound of abdomen and pelvis and MDP bone scan.
X-ray skeletal survey can be substituted if bones scan facility in not available.
PET-CT is not routinely recommended for metastatic work-up .Further imaging is required if equivocal finding is seen on any of the above mentioned imaging tests.This may include CECT of chest, abdomen and pelvis, MRI or PET-CT .
Image guided biopsy of metastatic lesions is not required if imaging findings are fairly suggestive of metastases. However, biopsy may be required if imaging findings are equivocal or if there is a single lesion which may alter the intent of management.
PATIENTS WITH METASTASIS FROM CANCER OF UNKNOWN PRIMARY SITE
These include women presenting with axillary lymph nodes or other lesions in the body which show malignancy on FNAC or biopsy.
Bilateral mammography is recommended to exclude breast cancer.
If mammography is positive then image guided biopsy should be performed. Ultrasound and if required CEMRI of breasts should be performed if mammography is equivocal.
CEMRI is also recommended if mammography is normal but patient has unilateral axillary lymphadenopathy and breast cancer is suspected on FNAC/biopsy of lymph nodes .
PATIENTS WITH TREATED BREAST CANCER ON FOLLOW-UP
Regular physical examination and annual mammography is recommended .
Mammograms must be compared with previous mammograms, even if these appear normal.
Any suspicious or new lesion not typically benign should be subjected to biopsy.
Follow-up systemic imaging to detect metastases is not routinely recommended, unless patient issymptomatic .
If metastases are detected on follow-up, its biopsy is not required if imaging findings are typical of metastases.
However, image guided core biopsy of new metastasis is required to assess hormonereceptor status if it has developed after long follow-up.
It is also required if receptor status of breast cancer is not already known .
BREAST ULTRASOUND
INTRODUCTION
Ultrasound breast is the investigation of choice in symptomatic young women and it is also used as an adjunct tool with Mammography in women with dense breasts.It helps in better characterisation of breast masses and differentiation between benign and malignant .These practice guidelies has been developed to assist breast radiologist in performing ultrasound examination of the breast. It will also help them when ultrasound is used as guidance for interventional procedures or biopsy.
INDICATION
DIAGNOSTIC
1.Evaluation and characterization of palpable masses and other breast related signs and/or symptoms.
2.Evaluation of suspected or apparent abnormalities detected on other imaging studies, suchas mammography or magnetic resonance imaging (MRI).
3.Initial imaging evaluation of palpable masses in women under 35 years of age who are notat high risk for development of breast cancer, and in lactating and pregnant women.
4.Evaluation of problems associated with breast implants.
5.Guidance of breast biopsy and other interventional procedures.
6.Treatment planning for radiation therapy.
SCREENING
As a supplement to mammography, screening for occult cancers in certain populations of women (such as those with dense fibroglandular breasts who are also at elevated risk ofbreast cancer) who are not candidates for MRI or have no easy access to MRI.
At present ultrasound is not considered a primary screening modality in other populations.
EQUIPMENT AND TECHNICAL FACTORS
Breast ultrasound should be performed with a high-resolution real-time linear array scanner operating at a centre frequency of at least 10 MHz and preferably higher. Masscharacterization with ultrasound is highly dependent on technical factors.Proper depth,gain, and focal zone settings should be optimized to obtain high-quality images. The patientshould be positioned to minimize the thickness of the portion of the breast being evaluated.For evaluation of superficial lesions, a standoff device or use of a thick layer of gel may behelpful specially in nipple areolar complex.
ULTRASOUND EVALUATION CRITERIA
1.Breast ultrasound should be correlated with clinical signs and/or symptoms and withmammographic and other breast imaging studies and should be directed in area of question.
2.It should be compared with prior ultrasound finding if available
3.A lesion or any area of the breast should be viewed in 2 perpendicular projections.
4.The size of a lesion should be taken in its maximal dimensions in at least 2 planes(orthogonal planes are recommended). At least 1 set of images of a lesion should beobtained without callipers.
5.The images should be labelled as to right or left breast, location of lesions, and the orientation of the transducer with respect to the breast (e.g., transverse or longitudinal,radial or antiradial).
6.The location of the lesion should be recorded using o’ clock position and distance from the nipple or can be shown on the diagram of the breast.
7.Ultrasound features are helpful in characterizing breast masses. These features should include size, shape, orientation, margin, echogenicity, lesion boundary, attenuation (e.g.,shadowing or enhancement), special cases, vascularity, and surrounding tissue. Features may also be described using the American College of Radiology Breast Imaging Reportingand Data System (BI-RADS) lexicon for ultrasound breast.
8.Elastography, or tissue stiffness assessment, is among the new feature categories applicableto ultrasound analysis of masses, may be included in the Associated Findings section in BI-RADS – Ultrasound.
IMAGING GUIDED BREAST BIOPSY
The scope of this document is limited to imaging guided percutaneous breast biopsy for diagnostic purposes and routinely performed therapeutic procedures such as abscess drainage and cyst aspiration.
For additional information on therapeutic procedures reference can be made to a number of well knownguidelines, such as ACR Breast Imaging and Intervention Practice Guidelines and Technical Standardsand CAR Practice Guidelines and Technical Standards for Breast Imaging and Intervention .
INTRODUCTION
The objective of imaging guided percutaneous breast biopsy is to obtain a histopathology diagnosis of a suspicious breast lesion without the patient having to undergo an invasive surgical procedure. The fact is that 70-80% of breast lesions that are biopsied are benign .If a trucut or core biopsy yields a benign diagnosis which is concordant with the imaging features,surgery can be avoided . While, if imaging guided percutaneous biopsy confirms the diagnosis of cancer, a single surgical procedure can be planned.
Also the likelihood of obtaining clear histologic margins at first operation is higher if there is preoperative histologic diagnosis of breast cancer].
Image guidance should be used for biopsy of both palpable and non-palpable breast lesions such that the most suspicious part of the lesion can be targeted. Palpation guidance is advised if the lesion is not visualised by any imaging modality .
There are two factors that need to be considered while performing an imaging guided breast biopsy. The first factor is the selection of the imaging modality on which the breast lesion is best visualized and the second factor is the selection of the breast biopsy device.
Whenever achievable, while performing a biopsy, the shortest distance from the skin to the lesion should be used .
TYPES OF DIAGNOSTIC BREAST INTERVENTIONALPROCEDURES
1.Fine needle aspiration cytology (FNAC)
2.Spring-loaded core needle biopsy (CNB)
3.Pre-surgical wire localization
ULTRASOUND GUIDANCE
Ultrasound guidance is the method of choice when a lesion is visualized sonographically. Prior to the performance of any ultrasound-guided percutaneous procedure, the findings should be assessed sonographically and where possible correlation with the mammographic finding should be made.
Indications
•Suspicious solid or complex solid-cystic masses (BI-RADS® 4 and 5 lesions)
•Targeted suspicious ultrasound-detected lesions following MRI (second-look ultrasound followingMRI)
•BI-RADS® 3 lesions at patient request, if follow-up is not possible (usual problem in developingcountries, remotely located women etc) or if there is another lesion in either of the breasts which is already diagnosed as cancer and surgery is planned (can’t wait for 6 months!)
Needle Selection:
•FNAC -
•Indications:
1) Axillary lymph node biopsy when there is a known or suspected ipsilateral breastmalignancy
2) Investigation of suspected multicentric/multifocal malignancy when the indexlesion has undergone a CNB/FNAC confirming malignancy in the index lesion
•Limitations of FNAC
— Cytologist dependent
— No information on type of cancer or receptors (ER, PR, Cerb2, Ki67)
— Incidence of false negative and false positive higher than with CNB
— If cost is the only deciding factor, then FNAC could be performed acknowledgingthe fact that discordant imaging and FNAC findings would warrant a repeat biopsy.
CNB -
Spring-loaded 14 Gauge CNB can be used for most solid breast lesions visualized onultrasound. When using an automated spring-loaded biopsy device, 14 gauge needle (or larger) isrecommended . A minimum of four 14 gauge cores is recommended for solid masses .
ABSCESS DRAINAGE AND CYST ASPIRATION
Abscesses less than 3.0 cms can be percutaneously drained under imaging guidance with a larger bore needle typically 18 gauge or larger, while abscesses greater than 3.0 cms may require percutaneous catheter insertion or surgical incision and drainage .
Other factors that determine the success of percutaneous abscess drainage are consistency of the abscess fluid and presence or absence of internal septations within the abscess cavity.
Typically, aspiration of non-complicated, benign cysts is not indicated.
Fine needle aspiration of a cyst is indicated if a cyst gets painful, larger than 5.0 cm causing discomfort to the patient, if the patient is anxious or if there is diagnostic uncertainty.
Fluid aspirated from a cyst can be discarded if it is non-bloody .
Cytology assessment of aspirated fluid is warranted if the fluid is hemorrhagic or the cyst does not collapse completely post aspiration.
CONTRAINDICATIONS FOR IMAGING GUIDED BREASTBIOPSIES
•Inability to visualize lesion (absolute)
•Anticoagulation:Discussion with the referring physician on a case by case basis isrecommended if reversal of anticoagulation is considered
COMPLICATIONS OF IMAGING GUIDED BREAST BIOPSIES
•Vasovagal attack (Immediate complication)
•Hematoma
•Infection
- Trauma to chest wall/pneumothorax (rare)
- Trauma to neurovascular structures in axilla
- Implant perforation
- Milk fistula during lactation
Public Awareness
- Breast Self Examination(BSE)
- Mammography
- Ultrasound
- Magnetic Resonance Imaging
- ‘Dense’ Breasts
- Biopsy
Breast Self Examination(BSE)
Breast self examination should be done atleast once a month. Women should be aware of how their breasts normally look and feel and report any new breast change. Finding a breast change however does not necessarily mean there is a cancer. Women with breast implants can also do BSE. It should begin at about the age of 20 years and continue the practice throughout their lives. Best time to examine breasts is when they are not tender or swollen such as few days after your period ends.
5 steps
Step 1-Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
Here’s what you should look for:
- Breasts that are their usual size, shape, and color
- Breasts that are evenly shaped without visible distortion or swelling
If you see any of the following changes, bring them to your doctor’s attention:
- Dimpling, puckering, or bulging of the skin
- A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)
- Redness, soreness, rash, or swelling.
Step 2- Now, raise your arms, clasp your hands behind your head and press your hands forward and look for the same changes.
Step 3- Look for any signs of fluid coming out of one or both nipples
(this could be a watery, milky, or yellow fluid or blood).
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. Use a
firm, smooth touch with the first few finger pads of your hand, keeping the
fingers flat and together. Use a circular motion, about the size of a quarter.
Cover the entire breast from top to bottom, side to side from your collarbone
to the top of your abdomen, and from your armpit to your cleavage.
Step 5- Finally, feel your breasts while you are standing or sitting. Many
women find that the easiest way to feel their breasts is when their skin is wet
and slippery, so they like to do this step in the shower. Cover your entire
breast, using the same hand movements described in step 4.
Mammography
It is advisable to perform mammography soon after your menstrual cycle as this is known to minimize the discomfort that may occur.
Application of deodorant/antiperspirant/talcum powder is to be avoided on the day of the study as the particulate matter in these products may alter the findings.
Breast Ultrasound
Ultrasound, also known as ultrasonography, is an imaging method in which high-frequency sound waves are used to create images of blood vessels, tissues, and organs including the breast.
Breast ultrasound is often used to evaluate breast abnormalities that are found during mammography or a clinical breast exam. Women who have dense breasts on mammogram are also candidates for a correlative ultrasound.
There are no data to establish that annual screening with ultrasound (in women
without symptoms) will reduce deaths from breast cancer and hence, screening
with ultrasound is not backed with evidence.
In young women, who have symptoms (pain/lump) related to the breast, ultrasound
is the first imaging investigation to be performed.
This may be followed up with a mammogram or breast MRI depending upon the sonography results.
No specific preparation is required for a breast ultrasound. It can be
performed anytime during the menstrual cycle.
Breast Biopsy
If there is an abnormality on imaging that needs further clarification, your radiologist, in consultation with your doctor, may decide to get a needle test to confirm its nature. This involves taking a tiny piece of the size of a rice grain from the abnormality which is then assessed and reported by the pathologist. Should this procedure be recommended, the radiologist will discuss details and preparation with you.
Dense Breast
Occasionally, you may receive a mammogram result stating that the breasts are dense. What does this term mean and imply?
Breasts are made up of different types of tissue: fatty, fibrous, and
glandular. Fibrous and glandular tissues appear as white on a mammogram and
fatty tissue appears dark. If most of the tissue on a mammogram is fibrous
and/or glandular, the breasts are considered to be dense.
Because cancer cells also appear as white on a mammogram, the cancer may be
obscured on a mammogram in women with dense breasts.
Women found to have dense breasts on a screening study may require additional
imaging depending upon their individual risk for breast cancer.
Imaging with ultrasound or MRI can pick up some cancers that may be missed on a mammogram, but these methods also have disadvantages. Because they are highly sensitive, they may give a false-positive reading, which may need additional testing or biopsy that was not necessary.
Breast Cancer
Diagnosing breast cancer
Core needle biopsy
Tests and procedures used to diagnose breast cancer include:
- Breast exam. Your doctor will check both of your breasts and lymph nodes in your armpit, feeling for any lumps or other abnormalities.
- Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality.
- Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-filled cyst.
- Removing a sample of breast cells for testing (biopsy). A biopsy is the only definitive way to make a diagnosis of breast cancer. During a biopsy, your doctor uses a specialized needle device guided by X-ray or another imaging test to extract a core of tissue from the suspicious area. Often, a small metal marker is left at the site within your breast so the area can be easily identified on future imaging tests.
Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment options.
- Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. Unlike other types of imaging tests, an MRI doesn’t use radiation to create the images.
Other tests and procedures may be used depending on your situation.
Correct information is .. half the war won already
DIAGNOSIS OF BREAST CANCER: CORE BIOPSY
WHat does ‘Tissue diagnosis’ mean?
Tissue Diagnosis: Tissue diagnosis means establishing the presence of cancer by observing the involved tissue under microscope. This is the single most important investigation (for any cancer, for that matter) and is a must before any form of treatment can be carried out.
How is tissue diagnosis achieved?
Tissue diagnosis can be achieved by the following means:
- FNAC
(Fine needle Aspiration Cytology): In this procedure, a fine needle attached to a
syringe is inserted into the tumour, and moved in and out multiple times (multi
pass), and while the in out movement is done, aspiration by the syringe is
continued. This will result in some cells from the tumour coming into the
needle, due to ‘suction’ action of the syringe. Immediately, the material is
collected on a slide and ‘fixed’, and then the slide is viewed under the
microscope. By observing the features of the aspirated cells under the
microscope, we can establish the diagnosis of cancer in most cases.
On clinical examination, if the tumour is not locally advanced and if we are contemplating surgery as the first form of treatment , FNAC can be done for diagnosis. - Core Biopsy: In this procedure, a special instrument, called as the ‘core biopsy gun’ is used. The skin over the tumour area is infiltrated with a local anesthetic, a small nick is taken, and the needle is inserted into the tumour and the gun is fired. This will give us linear bits of tissues from the tumour. The advantage of this method is, we are deriving a proper tissue of the tumour, and so apart from histopathology, other tests to espitmate the hormonal receptor status and HER2 receptor stauts can also be done on this. Hence, for any form of breast cancer, where we intend to give chemotherapy first, a core biopsy is compulsory, since in many patients, the tumour may completely disappear after chemotherapy, and then we will not have any tumour to assess for other details. This implies that for large operable cancers where we intend to give chemotherapy first, for locally advanced cancer,s and for metastatic breast cancers, core biopsy has to be done first. Also, in some cases of operable breast cancer, an FNAC may be equivocal, and may not achieve diagnosis. In such cases too, a core biopsy is indicated.
- Open biopsy: In open biopsy, the patient is anesthetised in the operating room, and a formal surgery is done, where tumour is excised completely and sent for histopathology. This is rarely, if ever, needed today.
Breast Hookwire Localisation
What is a breast hookwire localisation?
Mammography and ultrasound scan images or pictures sometimes show abnormalities in the breast that cannot be felt by a doctor. If the abnormality is to be surgically removed, it is necessary to place a fine wire, called a hookwire, in the breast with its tip at the site of the abnormality. This acts as a marker during surgery and enables the surgeon to remove the correct area of breast tissue.
The hookwire is inserted to guide the removal of both benign (non-cancerous) and malignant (cancerous) abnormalities. Ultrasound scan is used by the Radiologist (specialist doctor) to place the hookwire into the correct position. The wire is called a hookwire because there is a tiny hook at the end, which keeps it in position.
Breast hookwire localisation is done using local anaesthetic to numb the breast in the area where the hookwire is to be inserted.
How do I prepare for a breast hookwire localisation?
Usually, this procedure will be performed a few hours (or less) before you have surgery to remove the abnormality. There is no preparation required for the hookwire localisation, but there will be preparation for the surgery done after the hookwire localisation. Preparation instructions/information for the surgery will be given to you by the hospital where you are having the surgery done.
You should bring with you to the hookwire localisation any recent mammograms, ultrasounds or MRI scans and the reports for the radiologist performing the procedure to review before you have the hookwire localisation. Your surgeon will organise how this should be arranged (whether you bring them on the day or whether they are forwarded to the radiologist in advance).
What happens during a breast hookwire localisation?
The radiologist will choose the method of imaging guidance for the localisation usually depending on which type of imaging found the abnormality, which type of imaging shows the area best, and what the surgeon prefers, after discussion with you.
You will lie comfortably on an examination couch and the radiologist will find the abnormality with the ultrasound probe (a small smooth hand held device that is moved backwards and forwards across the skin of the breast). The breast is washed with antiseptic and the radiologist will place a very fine needle into the breast with local anaesthetic to numb the area where the hookwire is to be inserted.
The radiologist will then insert a fine needle into the tissue to be removed. The position of the needle is checked with the ultrasound probe. Once the needle is in the correct position, a fine wire is passed down the centre of the needle and the needle is removed, leaving the wire in place. A final mammogram is performed to show the surgeon where the tip of the wire lies in relation to the abnormality that is to be removed (a mammogram provides a better visual image for the surgeon of where the tip of the wire lies than ultrasound).
After the procedure
Whichever method is used for guidance of the hookwire placement, a piece of the fine wire is left sticking out from the breast. After the procedure, this piece of wire is taped down to the skin and the hookwire remains in the abnormality in the breast. The surgeon will remove the wire together with the abnormality at the time of the operation. Your previous imaging and the images from the breast hookwire localisation will be sent with you to the operating theatre so that the surgeon may refer to them.
Are there any after effects of a breast hookwire localisation?
As the hookwire will be removed at the time of the operation there are no after effects of the procedure itself.
The most common problem encountered is that some women may feel light headed during the procedure, which may be related to stress.
You can talk to your doctor or the hospital or radiology practice about how you can help to reduce your stress levels prior to having the procedure.
How long does a breast hookwire localisation take?
Takes approximately 30 minutes.
What are the risks of a breast hookwire localisation?
Hookwire localisation is a simple procedure to perform and most women have no problems. Some problems that can occur are:
- Some women may be allergic to local anaesthetic, although this is rare.
- The hookwire can move after placement and before having the surgery, which reduces the accuracy of the surgery.
- Fragments of wire are occasionally left in the breast after surgery (as the result of accidental clipping or fragmentation of the wire). These rarely cause harm as they are made from the same material as surgical clips used routinely in many operations and seldom require removal.
- Wire dislodgement. This occurs usually because the breast is composed of fatty tissue which provides a poor grip for the hookwire. While the most usual cause of dislodgement is the nature of the breast tissue, if you are travelling to another facility for your surgery with a hookwire in position you need to take care, i.e. do not carry luggage or take public transport. Dislodgement may occasionally occur with very little movement. If dislodgement occurs, you may need to have the procedure performed again because the tip of the wire will no longer be situated in the lesion that needs to be removed.
What are the benefits of a breast hookwire localisation?
Hookwire localisation assists a surgeon in the removal of breast abnormalities that cannot be felt. It marks where the abnormal tissue is located and enables the surgeon to remove the smallest amount of abnormal tissue identified on mammograms and ultrasound scans. As only the abnormal tissue is removed (with a margin of clear tissue around it), scarring can be minimised and the shape of the breast can be preserved as far as possible.
When can I expect the results of my breast hookwire localisation?
The hookwire procedure is a guide for the surgeon. As it is not an investigation, there are usually no results for the hookwire procedure itself other than a written description of what was done and the guidance images. The surgeon will give you the pathology results (where the abnormal tissue is examined for any disease) for the tissue removed, when you have your appointment with the surgeon after the operation.
WARNING SIGNS OF BREAST CANCER
Due to the regular use of mammography screening, many breast cancers can be found at an early stage, before warning signs appear.
However, not all breast cancers are found through mammography.
Warning signs
The warning signs of breast cancer are not the same for all women.
The most common signs are:
- A change in the look or feel of the breast OR
- A change in the look or feel of the nipple OR
- Nipple discharge
If you have any of the warning signs described below, see a Breast Specialist Doctor .
In most cases, these changes are not cancer.
One example is breast pain. It’s more
common with benign breast
conditionsthan with breast cancer, but the only way to know for sure is to
get it checked.
If the change does turn out to be breast cancer, it’s best to find it at an
early stage, when the chances of survival are highest.
Breast lumps or lumpiness
Many women may find their breasts feel lumpy. Breast tissue naturally has a bumpy texture.
Some women have more lumpiness in their breasts than others. In most cases, this lumpiness is no cause to worry.
If the lumpiness can be felt throughout the breast and feels like your other breast, then it’s likely normal breast tissue.
Lumps that feel harder or different from the rest of the breast (or the other breast) or that feel like a change should be checked. This type of lump may be a sign of breast cancer or a benign breast condition (such as a cyst or fibroadenoma).
See a health care provider if you:
- Find a new lump (or any change) that feels different from the rest of your breast
- Find a new lump (or any change) that feels different from your other breast
- Feel something that’s different from what you felt before
If you’ve had a benign lump in the past, don’t assume a new lump will also be benign. The new lump may not be breast cancer, but it’s best to make sure.
Nipple discharge
Liquid leaking from your nipple (nipple discharge) can be troubling, but it’s rarely a sign of breast cancer.
Discharge can be your body’s natural reaction when the nipple is squeezed.
Signs of a more serious condition (such as breast cancer) include discharge that:
- Occurs without squeezing the nipple
- Occurs in only 1 breast
- Is bloody or clear (not milky)
Nipple discharge can also be caused by an infection or other condition that needs treatment.
If you have any nipple discharge, see a health care provider.