Detecting Breast Cancer
The earlier a breast cancer is found, the better your chances for successful treatment. Early stages of breast cancer commonly do not produce symptoms, so it’s vital to have mammograms and clinical breast exams according to schedule. If you notice a symptom such as a lump, nipple discharge, or changes in the skin such as redness or skin retraction, report this immediately to your doctor. The doctor will take a full history, asking questions about when you first noticed the problem and whether the symptoms change according to the timing of your menstrual cycle. Your doctor will examine your breasts and the lymph node areas under your arms and around your collarbones, and will outline a plan for further evaluation, which frequently includes a mammogram with breast ultrasound.
A good approach for both you and your doctor is to suspect cancer until it’s been ruled out and to move along to each diagnostic step promptly. If you or your doctor notice a lump or other abnormality, request an ultrasound in addition to the mammogram if your doctor does not suggest one. Mammogram plus ultrasound is now the standard of care. If you are premenopausal, your doctor may advise waiting and reexamining you after two menstrual periods have passed; if the lump remains, he or she will refer you to a surgeon for biopsy. If mammogram and ultrasound do not show a cyst or a solid tumor, and you are past menopause, your primary care doctor should refer you to a breast surgeon for further examination. Most breast surgeons will recommend a biopsy, because it’s preferable to use a fairly safe biopsy procedure than to assume a lump is harmless when it’s not.
If your surgeon doesn’t recommend a biopsy but you still feel the lump is present or your breast feels different than usual, insist on one.
A good approach for both you and your doctor is to suspect cancer until it’s been ruled out and to move along to each diagnostic step promptly. If you or your doctor notice a lump or other abnormality, request an ultrasound in addition to the mammogram if your doctor does not suggest one. Mammogram plus ultrasound is now the standard of care. If you are premenopausal, your doctor may advise waiting and reexamining you after two menstrual periods have passed; if the lump remains, he or she will refer you to a surgeon for biopsy. If mammogram and ultrasound do not show a cyst or a solid tumor, and you are past menopause, your primary care doctor should refer you to a breast surgeon for further examination. Most breast surgeons will recommend a biopsy, because it’s preferable to use a fairly safe biopsy procedure than to assume a lump is harmless when it’s not.
If your surgeon doesn’t recommend a biopsy but you still feel the lump is present or your breast feels different than usual, insist on one.
Warning Signs of Breast Cancer
Often breast cancer has no symptoms, but there are certain clues that can serve as a warning for breast cancer. When examining your breasts every month, pay attention to their appearance and consult your doctor about any changes you see, such as the following:
Nipple discharge. It’s not unusual for nipples to leak fluid; after all, they’re built to discharge milk. If the nipples are stimulated — during sex, by persistent squeezing, or during a mammogram — the breasts may react and produce whatever fluid they contain. Birth control pills, blood pressure drugs such as Aldomet, tranquilizers such as Thorazine, or marijuana can cause normal, benign nipple discharge, usually in both breasts and from multiple ducts. Another type of nipple discharge is galactorrhea, a spontaneous, persistent production of milk from both breasts when the woman isn’t breast-feeding.
The kind of discharge that may indicate disease usually occurs only from one duct of one nipple and is spontaneous (not caused by nipple stimulation). The cause most often is one or several papillomas (nonmalignant, pimple-like growths in the lining of a breast duct) or duct ectasia (an inflammation of the lining of the milk gland). Less commonly, the discharge is the sign of a cancer, either DCIS or an invasive cancer. Surgery usually is required to make a diagnosis. The surgeon identifies the duct and removes it through an incision in the skin. In the laboratory, a pathologist examines the tissue for cancer cells.
Inverted nipples. Inverted nipples are not uncommon, and some women live with one or both nipples inverted for most of their lives. If the nipple inversion is a recent occurrence, however, it may be a sign of cancer. Your doctor should examine you and refer you for a mammogram; a biopsy may be necessary to obtain a diagnosis.
Paget disease of the breast. This form of cancer may first appear as an itchy sore on the nipple and can progress to crustiness and oozing that fails to improve. It is a rare cancer. Although it resembles eczema, eczema almost always affects only the areola, the dark area around the nipple. Paget’s disease is the opposite: It affects the nipple and not the areola. The diagnostic approach includes a mammogram and examination of the breast and a biopsy of the nipple skin. If it’s cancer, the cancer cells can be seen under a microscope, growing into the skin. In most patients there’s an underlying breast cancer. If the cancer involves only the nipple, Paget’s disease has a better prognosis than other breast cancers. Historically, many breast surgeons preferred to remove the entire breast to treat this cancer, even when only the nipple area was affected. Today, however, just the nipple and the areola are removed, along with the underlying cancer, and the unaffected portion of the breast is spared. (Paget’s disease of the breast should not be confused with Paget’s disease of the bone or Paget’s disease of the eyelids. All are named for their discoverer, English surgeon James Paget.)
Nipple discharge. It’s not unusual for nipples to leak fluid; after all, they’re built to discharge milk. If the nipples are stimulated — during sex, by persistent squeezing, or during a mammogram — the breasts may react and produce whatever fluid they contain. Birth control pills, blood pressure drugs such as Aldomet, tranquilizers such as Thorazine, or marijuana can cause normal, benign nipple discharge, usually in both breasts and from multiple ducts. Another type of nipple discharge is galactorrhea, a spontaneous, persistent production of milk from both breasts when the woman isn’t breast-feeding.
The kind of discharge that may indicate disease usually occurs only from one duct of one nipple and is spontaneous (not caused by nipple stimulation). The cause most often is one or several papillomas (nonmalignant, pimple-like growths in the lining of a breast duct) or duct ectasia (an inflammation of the lining of the milk gland). Less commonly, the discharge is the sign of a cancer, either DCIS or an invasive cancer. Surgery usually is required to make a diagnosis. The surgeon identifies the duct and removes it through an incision in the skin. In the laboratory, a pathologist examines the tissue for cancer cells.
Inverted nipples. Inverted nipples are not uncommon, and some women live with one or both nipples inverted for most of their lives. If the nipple inversion is a recent occurrence, however, it may be a sign of cancer. Your doctor should examine you and refer you for a mammogram; a biopsy may be necessary to obtain a diagnosis.
Paget disease of the breast. This form of cancer may first appear as an itchy sore on the nipple and can progress to crustiness and oozing that fails to improve. It is a rare cancer. Although it resembles eczema, eczema almost always affects only the areola, the dark area around the nipple. Paget’s disease is the opposite: It affects the nipple and not the areola. The diagnostic approach includes a mammogram and examination of the breast and a biopsy of the nipple skin. If it’s cancer, the cancer cells can be seen under a microscope, growing into the skin. In most patients there’s an underlying breast cancer. If the cancer involves only the nipple, Paget’s disease has a better prognosis than other breast cancers. Historically, many breast surgeons preferred to remove the entire breast to treat this cancer, even when only the nipple area was affected. Today, however, just the nipple and the areola are removed, along with the underlying cancer, and the unaffected portion of the breast is spared. (Paget’s disease of the breast should not be confused with Paget’s disease of the bone or Paget’s disease of the eyelids. All are named for their discoverer, English surgeon James Paget.)
Breast Self-Exam and Clinical Exam
Several exams can detect breast cancer. Some are used for routine screening, and others are used only when screening shows a possible abnormality or when a woman has a symptom, such as a breast lump. Usually more than one exam is needed to diagnose breast cancer. No one method is completely reliable except biopsy, in which some of the suspicious tissue is removed and examined under a microscope.
Breast self-exam
Checking your own breasts every month can be useful, but you shouldn’t rely on this method as the only way to screen for breast cancer. By the time you can feel a lump, it’s probably half an inch or larger. Mammography can detect cancers of smaller sizes.
Check your breasts on the same day every month, preferably seven days after your period begins. This is when the hormones from the ovaries are at their lowest levels and the breasts are least engorged, and it is the best time to feel any irregularity that may be present. Women who have gone through menopause should examine their breasts on the same day each month, such as on the first day of the month. Women also sometimes find lumps while showering, while applying body lotion, or during sex.
To perform a breast self-exam, begin by looking at your breasts in a mirror, first with your arms at your sides, then with your hands on your waist and bending forward slightly, and finally with your arms raised over your head. Look for asymmetries of the breast, dimpling of the skin, redness of the skin, new retraction of a nipple, and evidence of nipple discharge.
Then, either lying down or standing in the shower, examine your breasts for any bumps, lumps, or thickening. Place one arm behind your head and, with your opposite hand holding fingers flat, examine all areas of the breast in a circular, organized fashion so no part is overlooked. First press lightly, then a bit more firmly and then very firmly in each area (the three-layer cake technique). You should then drop the arm, place the opposite arm behind your head, and examine your other breast in the same way. Pay particular attention to the areas between the breasts (over the breastbone) and under the arms, because mammograms may not reach these areas. Also, because some cancers occur in the nipple/areola area, feel this area carefully.
Clinical breast exam
Because mammograms fail to detect 10%–15% of breast cancers, it’s important to have an annual breast examination by a doctor or other health care professional. For the clinical breast examination, you will undress from the waist up and put on a gown. The doctor will first look at your breasts for any signs of cancer and then palpate or press on your breasts, and the lymph node areas under your arms and around your collarbone to detect any lumps.
Mammography
Mammography is the most common method for detecting abnormalities in the breast. This screening technique is an x-ray that uses very low levels of radiation. It can find 85%–90% of breast cancers. Mammography makes it possible to see tiny cancers that may measure as little as half a centimeter (about one-fifth of an inch). Generally, a lump can’t be felt until it’s at least twice that size. The abnormalities that show up on a mammogram may be benign or malignant (see What the Radiologist Sees 
).
Research shows that annual mammography saves lives in women ages 50 and older and suggests that it also reduces mortality in women ages 40–49. The American Cancer Society and other medical groups recommend that women have an annual mammogram starting at age 40. Women who are at high risk for breast cancer because of a family history or other factors may begin screening at an earlier age (see If You Are at High Risk for Breast Cancer). The downside of mammography is that it has increased the number of biopsies in women who do not have breast cancer.
The mammography procedure. To obtain a clear picture of the breast tissue, a technician will ask you to stand with your breast on a platform and will pull the breast away from your body so the image can show as much breast tissue as possible. The machine will compress your breast briefly between two plastic plates while it takes the x-ray picture. As soon as the x-ray is made, the plates automatically release. Horizontal and vertical views are made of each breast. Some women find the compression painful; most find it merely uncomfortable. Fortunately, the compression lasts only seconds. If certain areas of the breast don’t show up clearly on the mammograms when they’re read by the radiologist (a doctor who specializes in interpreting these types of images), you may need to take additional views. This happens in 5%–10% of screening mammograms. Afterward, you will either be asked to wait until the radiologist has read each film, or you will receive the results in the mail a few days later. If the results indicate a concern, the center will contact you by phone rather than mailing the results.
On a mammogram, the structures inside your breast appear in shades ranging from white to black. The white areas are mainly milk ducts. The hazy gray and black areas are fat tissue. Abnormalities appear as white spots of two types: densities or calcifications.
Densities. These abnormalities appear as light spots on the mammogram. If a density appears on a mammogram, the radiologist will examine it with two or more different mammographic views. A density may or may not indicate cancer. A density with a starburst shape (arms radiating outward from the center) is called "spiculated" and often indicates cancer. Noncancerous densities usually appear as a spot with a smooth outline and no arms radiating outward. If a density appears on a mammogram, the next step is usually a breast ultrasound (see Breast Ultrasound).
Calcifications. These abnormalities appear as tiny, sand-grain-sized bright white dots. Most calcifications are benign. Benign calcifications are usually scattered randomly through both breasts, almost like a snowstorm. Or, benign calcifications may be clustered in a small space and are usually similar in size and may be coarse in appearance. If the calcifications appear to be benign, you and your doctors can monitor any further changes with yearly mammograms. Calcifications that appear as tiny dots of different sizes and shapes (pleomorphic) in a line (linearly arranged) are likely inside a duct and generally indicate cancer. More than 70% of suspicious indications that are biopsied turn out to be benign.
Assessing the mammogram. Radiologists use standard terminology for classifying the findings of a mammogram. The radiologist will use numbered categories to refer to the shape and margins of a mass, the appearance and distribution of calcifications, and the radiologist’s level of suspicion that the abnormality represents a breast cancer. Such a classification system provides a common language for communication between radiologists, clinicians, and the women having the mammograms, regardless of where the procedure has been done. The categories were developed by the Breast Imaging Reporting and Data System (see BI-RADS Assessment Categories ).
). Research shows that annual mammography saves lives in women ages 50 and older and suggests that it also reduces mortality in women ages 40–49. The American Cancer Society and other medical groups recommend that women have an annual mammogram starting at age 40. Women who are at high risk for breast cancer because of a family history or other factors may begin screening at an earlier age (see If You Are at High Risk for Breast Cancer). The downside of mammography is that it has increased the number of biopsies in women who do not have breast cancer.
The mammography procedure. To obtain a clear picture of the breast tissue, a technician will ask you to stand with your breast on a platform and will pull the breast away from your body so the image can show as much breast tissue as possible. The machine will compress your breast briefly between two plastic plates while it takes the x-ray picture. As soon as the x-ray is made, the plates automatically release. Horizontal and vertical views are made of each breast. Some women find the compression painful; most find it merely uncomfortable. Fortunately, the compression lasts only seconds. If certain areas of the breast don’t show up clearly on the mammograms when they’re read by the radiologist (a doctor who specializes in interpreting these types of images), you may need to take additional views. This happens in 5%–10% of screening mammograms. Afterward, you will either be asked to wait until the radiologist has read each film, or you will receive the results in the mail a few days later. If the results indicate a concern, the center will contact you by phone rather than mailing the results.
On a mammogram, the structures inside your breast appear in shades ranging from white to black. The white areas are mainly milk ducts. The hazy gray and black areas are fat tissue. Abnormalities appear as white spots of two types: densities or calcifications.
Densities. These abnormalities appear as light spots on the mammogram. If a density appears on a mammogram, the radiologist will examine it with two or more different mammographic views. A density may or may not indicate cancer. A density with a starburst shape (arms radiating outward from the center) is called "spiculated" and often indicates cancer. Noncancerous densities usually appear as a spot with a smooth outline and no arms radiating outward. If a density appears on a mammogram, the next step is usually a breast ultrasound (see Breast Ultrasound).
Calcifications. These abnormalities appear as tiny, sand-grain-sized bright white dots. Most calcifications are benign. Benign calcifications are usually scattered randomly through both breasts, almost like a snowstorm. Or, benign calcifications may be clustered in a small space and are usually similar in size and may be coarse in appearance. If the calcifications appear to be benign, you and your doctors can monitor any further changes with yearly mammograms. Calcifications that appear as tiny dots of different sizes and shapes (pleomorphic) in a line (linearly arranged) are likely inside a duct and generally indicate cancer. More than 70% of suspicious indications that are biopsied turn out to be benign.
Assessing the mammogram. Radiologists use standard terminology for classifying the findings of a mammogram. The radiologist will use numbered categories to refer to the shape and margins of a mass, the appearance and distribution of calcifications, and the radiologist’s level of suspicion that the abnormality represents a breast cancer. Such a classification system provides a common language for communication between radiologists, clinicians, and the women having the mammograms, regardless of where the procedure has been done. The categories were developed by the Breast Imaging Reporting and Data System (see BI-RADS Assessment Categories
). Breast Ultrasound
Breast ultrasound is an imaging test that uses painless high-frequency sound waves to help doctors evaluate whether a density that appears on a mammogram is a fluid-filled cyst, a solid mass, or a variation of normal breast tissue. A cyst is generally benign, and a solid mass may be either benign or malignant.
Ultrasound isn’t used for routine screening because it can’t show the entire breast at one time; it can only visualize small areas accurately. Also, it doesn’t show as much small detail as a mammogram does. Once a density is identified, however, ultrasound often can provide enough additional information to enable doctors to determine whether the density is harmful. It’s important to keep in mind that 1%–2% of breast cancers elude both ultrasound and mammography. So if there is a persistent change in your breast, a biopsy may be required even without any clear results from the ultrasound or mammogram.
To obtain good quality breast-imaging services and careful biopsies, your best choice is a breast health center or any medical facility that does many of these procedures and is accredited by the American College of Radiology.
Cyst or solid mass? If a density is a fluid-filled cyst, the ultrasound waves will go through it and a black "hole" or spot will appear on the ultrasound image. If it’s a solid mass, like a fibroadenoma or cancer, the waves will echo off, and it will appear as a white spot.
Ultrasound may be the easiest way to diagnose a cyst without using needle aspiration (see Fine Needle Aspiration Biopsy). A simple cyst is like a tiny water balloon; it contains only fluid and no debris. Even so, the doctor may perform a needle aspiration to remove the fluid from the cyst and confirm that the mass is a cyst and not solid. If a cyst doesn’t appear to be "clear" on ultrasound, needle aspiration is usually performed to see if cancer cells are hiding in it. A cyst will collapse after it’s drained, making it possible to see any abnormality that might have been concealed. A complex cyst — one that has an irregular shape or debris floating in its interior — needs to be aspirated under ultrasound guidance to see if it fully collapses after it’s drained, or whether it may have been concealing an abnormality.
If the mass is solid, the ultrasound exam can help the doctors determine whether the mass is benign or malignant. A benign mass is typically more horizontal ("lying down") and has a smooth outer border. A cancer is more vertical ("standing up"), with an irregular border. If the ultrasound shows a solid mass, a needle or surgical biopsy might be recommended.
Ultrasound isn’t used for routine screening because it can’t show the entire breast at one time; it can only visualize small areas accurately. Also, it doesn’t show as much small detail as a mammogram does. Once a density is identified, however, ultrasound often can provide enough additional information to enable doctors to determine whether the density is harmful. It’s important to keep in mind that 1%–2% of breast cancers elude both ultrasound and mammography. So if there is a persistent change in your breast, a biopsy may be required even without any clear results from the ultrasound or mammogram.
To obtain good quality breast-imaging services and careful biopsies, your best choice is a breast health center or any medical facility that does many of these procedures and is accredited by the American College of Radiology.
Cyst or solid mass? If a density is a fluid-filled cyst, the ultrasound waves will go through it and a black "hole" or spot will appear on the ultrasound image. If it’s a solid mass, like a fibroadenoma or cancer, the waves will echo off, and it will appear as a white spot.
Ultrasound may be the easiest way to diagnose a cyst without using needle aspiration (see Fine Needle Aspiration Biopsy). A simple cyst is like a tiny water balloon; it contains only fluid and no debris. Even so, the doctor may perform a needle aspiration to remove the fluid from the cyst and confirm that the mass is a cyst and not solid. If a cyst doesn’t appear to be "clear" on ultrasound, needle aspiration is usually performed to see if cancer cells are hiding in it. A cyst will collapse after it’s drained, making it possible to see any abnormality that might have been concealed. A complex cyst — one that has an irregular shape or debris floating in its interior — needs to be aspirated under ultrasound guidance to see if it fully collapses after it’s drained, or whether it may have been concealing an abnormality.
If the mass is solid, the ultrasound exam can help the doctors determine whether the mass is benign or malignant. A benign mass is typically more horizontal ("lying down") and has a smooth outer border. A cancer is more vertical ("standing up"), with an irregular border. If the ultrasound shows a solid mass, a needle or surgical biopsy might be recommended.
Magnetic Resonance Imaging (MRI) of the Breast
A breast MRI is a high-resolution way of visualizing the breast without radiation. It is useful when doctors suspect there is a tumor that is not showing up during a physical exam or mammography. It may also be used to determine the size and extent of a known tumor.
Breast MRI can be used in addition to mammography or ultrasound. Doctors use MRI when they suspect the presence of an "occult" breast cancer. This is when a woman has a swollen underarm lymph node that is found, by aspiration or biopsy, to contain cancer cells, yet no sign of cancer appears on a breast exam and mammogram. In most such patients, breast MRI can identify the site of the cancer. MRI can also be used to examine the chest wall or pectoral muscles for suspected cancer, as these areas are hard to reach with mammography.
Doctors also use breast MRI to determine the size and extent of a known tumor in a breast cancer patient. This is especially useful if the cancer is difficult to measure by mammography, as can be the case with an infiltrating lobular cancer. If you are taking anticancer drugs to shrink a tumor before surgery, a process called neoadjuvant therapy, MRI can help reveal whether the tumor is responding to the medication. In addition, MRI may be used to check for recurrences after lumpectomy.
Breast MRI requires special equipment designed specifically for breasts. To have an MRI, you lie very still within a large machine, face down, with your breasts suspended into a cushioned, bra-like holder. Your face and head are near the open ends of the magnet chamber. During the procedure, a dye is injected into your arm. Short bursts of high-frequency waves stimulate hydrogen atoms in cells to emit signals that are collected and turned into an image by a computer. The image is made in 5–10 sequences, each of which is 3–5 minutes long, with breaks in between. The entire examination takes about 45 minutes.
MRI is expensive and somewhat technically difficult. It requires a specialized machine and radiologists experienced in its use. Nevertheless, major medical centers are finding that breast MRI, used in conjunction with mammography and ultrasound, can be a powerful tool for some patients.
This imaging method has some limitations, however. It can produce false positive readings in which a benign abnormality might resemble a cancer. Another drawback is that MRI is able to identify DCIS in only 50% of patients. Because of these problems, MRI is not recommended for routine screening of women at low or average risk of breast cancer. However, some breast centers use MRI and mammography to screen women who are at very high risk of breast cancer because they carry a mutation of BRCA1 or BRCA2. MRI tends to be more sensitive than mammogram in women with these genetic mutations. Women in this group should have both a mammogram and MRI annually plus a clinical breast exam every six months.
Breast MRI can be used in addition to mammography or ultrasound. Doctors use MRI when they suspect the presence of an "occult" breast cancer. This is when a woman has a swollen underarm lymph node that is found, by aspiration or biopsy, to contain cancer cells, yet no sign of cancer appears on a breast exam and mammogram. In most such patients, breast MRI can identify the site of the cancer. MRI can also be used to examine the chest wall or pectoral muscles for suspected cancer, as these areas are hard to reach with mammography.
Doctors also use breast MRI to determine the size and extent of a known tumor in a breast cancer patient. This is especially useful if the cancer is difficult to measure by mammography, as can be the case with an infiltrating lobular cancer. If you are taking anticancer drugs to shrink a tumor before surgery, a process called neoadjuvant therapy, MRI can help reveal whether the tumor is responding to the medication. In addition, MRI may be used to check for recurrences after lumpectomy.
Breast MRI requires special equipment designed specifically for breasts. To have an MRI, you lie very still within a large machine, face down, with your breasts suspended into a cushioned, bra-like holder. Your face and head are near the open ends of the magnet chamber. During the procedure, a dye is injected into your arm. Short bursts of high-frequency waves stimulate hydrogen atoms in cells to emit signals that are collected and turned into an image by a computer. The image is made in 5–10 sequences, each of which is 3–5 minutes long, with breaks in between. The entire examination takes about 45 minutes.
MRI is expensive and somewhat technically difficult. It requires a specialized machine and radiologists experienced in its use. Nevertheless, major medical centers are finding that breast MRI, used in conjunction with mammography and ultrasound, can be a powerful tool for some patients.
This imaging method has some limitations, however. It can produce false positive readings in which a benign abnormality might resemble a cancer. Another drawback is that MRI is able to identify DCIS in only 50% of patients. Because of these problems, MRI is not recommended for routine screening of women at low or average risk of breast cancer. However, some breast centers use MRI and mammography to screen women who are at very high risk of breast cancer because they carry a mutation of BRCA1 or BRCA2. MRI tends to be more sensitive than mammogram in women with these genetic mutations. Women in this group should have both a mammogram and MRI annually plus a clinical breast exam every six months.
Breast Ductogram
Ductography, also called galactography, is a mammography technique used for evaluating the cause of spontaneous nipple discharge that occurs from a single duct in one breast. The procedure must take place when the fluid can be expressed from the breast so the correct duct can be examined.
The doctor inserts a slender, blunt-tipped catheter into the discharging duct and injects a small amount of contrast medium (dye that shows up on an x-ray image). The dye fills the duct, so when the mammogram is taken, the duct’s shape and internal contour is visible. The injection of dye may produce a temporary feeling of "fullness" in the breast but doesn’t cause pain or burning. If the radiologist sees a mass or other abnormality, that section of the duct can be surgically removed. If no distinct abnormality is apparent, the whole duct is removed for analysis. Most women with abnormal duct discharge do not have a malignancy.
The doctor inserts a slender, blunt-tipped catheter into the discharging duct and injects a small amount of contrast medium (dye that shows up on an x-ray image). The dye fills the duct, so when the mammogram is taken, the duct’s shape and internal contour is visible. The injection of dye may produce a temporary feeling of "fullness" in the breast but doesn’t cause pain or burning. If the radiologist sees a mass or other abnormality, that section of the duct can be surgically removed. If no distinct abnormality is apparent, the whole duct is removed for analysis. Most women with abnormal duct discharge do not have a malignancy.
Breast Biopsy
A biopsy or needle aspiration is often the next step when a mammogram or ultrasound suggests an irregularity, or when the doctor can feel a lump that has persisted for two menstrual cycles, even if mammography or ultrasound shows no further clues.
In a biopsy, a doctor removes a sample of tissue from a suspicious area so that a pathologist can evaluate the cells under a microscope for signs of cancer. The only way to do used to be a procedure called open surgical biopsy, in which a surgeon makes an incision and removes the suspicious area. Surgical biopsies leave scars and may change the size and shape of the breast. Today, doctors can often use newer techniques, such as core needle biopsy and fine needle aspiration, which have minimal cosmetic effects on the breast. This is a significant advantage, given that 80% of women who have biopsies turn out not to have cancer. If your health care facility does not perform needle biopsies, ask to be referred to one that does, unless there is a firm reason that this procedure is inappropriate for your condition.
In a biopsy, a doctor removes a sample of tissue from a suspicious area so that a pathologist can evaluate the cells under a microscope for signs of cancer. The only way to do used to be a procedure called open surgical biopsy, in which a surgeon makes an incision and removes the suspicious area. Surgical biopsies leave scars and may change the size and shape of the breast. Today, doctors can often use newer techniques, such as core needle biopsy and fine needle aspiration, which have minimal cosmetic effects on the breast. This is a significant advantage, given that 80% of women who have biopsies turn out not to have cancer. If your health care facility does not perform needle biopsies, ask to be referred to one that does, unless there is a firm reason that this procedure is inappropriate for your condition.
Fine Needle Aspiration Biopsy
A doctor can do fine needle aspiration in the office by inserting a slender needle into the area of concern and drawing out (aspirating) either fluid from a cyst or a small amount of tissue from a solid mass. Tissue from a mass, and sometimes fluid from a cyst, is then
sent for microscopic evaluation to determine whether cancer is present.
Fine needle aspiration is most commonly used to drain a palpable breast cyst that is tender for the patient. If the cyst is a simple cyst (one that looks clear under ultrasound) and isn’t tender, it doesn’t require aspiration. Aspiration is also used to empty a complex cyst — one that appears on ultrasound to contain not only fluid, but also debris — because in rare cases, the debris could represent cancerous cells. If the fluid that comes out during aspiration is bloody, that fluid is sent to be examined microscopically.
If the cells that are removed during aspiration are noncancerous, the doctor may still recommend further testing with a large core needle biopsy or open surgical biopsy if the lump feels questionable to the doctor or appears suspicious on mammography or ultrasound.
sent for microscopic evaluation to determine whether cancer is present.
Fine needle aspiration is most commonly used to drain a palpable breast cyst that is tender for the patient. If the cyst is a simple cyst (one that looks clear under ultrasound) and isn’t tender, it doesn’t require aspiration. Aspiration is also used to empty a complex cyst — one that appears on ultrasound to contain not only fluid, but also debris — because in rare cases, the debris could represent cancerous cells. If the fluid that comes out during aspiration is bloody, that fluid is sent to be examined microscopically.
If the cells that are removed during aspiration are noncancerous, the doctor may still recommend further testing with a large core needle biopsy or open surgical biopsy if the lump feels questionable to the doctor or appears suspicious on mammography or ultrasound.
Large Core Needle Biopsy
This method involves the use of a hollow needle to remove samples of breast tissue to be examined microscopically. Since the early 1990s, large core needle biopsy has been the diagnostic method of choice to evaluate abnormalities that are visible on a mammogram but cannot easily be felt by hand. In the more advanced medical centers, it is considered the standard of care. Large core needle biopsy can be performed using either mammographic (stereotactic) or ultrasound guidance. Mammographic calcifications (see Calcifications) are usually biopsied using the stereotactic method, whereas mammographic densities (see Densities) can be sampled by ultrasound guidance when the density is visible by ultrasound, and by stereotactic guidance when the density is visible only by mammography.
To perform a large core needle biopsy, the doctor anesthetizes the skin and inserts a needle the thickness of a pen-tip into the breast. Using the mammogram or ultrasound images, or by feeling the lump, the doctor guides the needle into the area of concern and removes a tissue sample through the needle with the help of a vacuum. Core needle biopsy may cause some bruising but leaves only a tiny dot for a scar. Core needle biopsy may not be suitable for patients who have an irregularity close to the chest wall, the nipple, or the surface of the breast; those with calcifications that require magnification; or women with very small breasts. In these situations, accurate results may not be possible and an open surgical biopsy (see Surgical Biopsy) will be recommended.
Stereotactic core needle biopsy. With this procedure, the mammographer or surgeon looks at a mammogram image while performing the biopsy in order to precisely locate the suspicious area. This method is useful when the doctor can see an abnormality on a mammogram but cannot feel it in a breast exam. The patient lies face down on a specially designed table with the breast compressed. The doctor injects a local anesthetic, makes a 3-mm skin incision, and then inserts the core biopsy needle. Usually results are available within a day or two. Women who cannot remain still for 20–40 minutes because of physical illness or other problems are not good candidates for stereotactic core needle biopsy.
Ultrasound guided core needle biopsy. With this method, the radiologist uses ultrasound imaging to precisely confirm the location for biopsy with the core needle. The doctor makes only a single puncture in the skin to extract three to six separate core needle tissue samples for analysis. The patient may feel some pressure but no pain. The procedure takes only a few minutes. Following the procedure, a bag of ice is placed on the site for 15 to 30 minutes, and most patients are able to resume normal activity almost immediately afterward.
Results of core needle biopsy. In experienced centers, 65% of women who undergo this procedure have a benign diagnosis and can resume having annual mammograms. Another 25% of patients have a malignancy and proceed with treatment.
For the remaining 10% of patients, results are inconclusive. For these patients, the next step is often a type of biopsy known as an excisional biopsy (see Surgical Biopsy). If the core biopsy suggests atypical ductal hyperplasia (see Types of Breast Cancer),surgical biopsy can help determine if the abnormality is atypical hyperplasia (81%), DCIS (13%), or an invasive breast cancer (6%). If, on the other hand, the core biopsy demonstrates tissue changes known as atypical lobular hyperplasia, then excisional biopsy is not necessary because, at worst, the abnormality might turn out to be a noncancerous condition known as lobular carcinoma in situ.
For patients whose core needle biopsy shows DCIS, the full lesion will need to be removed for further examination in the laboratory. For these patients, the likelihood of an invasive breast cancer ranges from 0% to 28%.
To perform a large core needle biopsy, the doctor anesthetizes the skin and inserts a needle the thickness of a pen-tip into the breast. Using the mammogram or ultrasound images, or by feeling the lump, the doctor guides the needle into the area of concern and removes a tissue sample through the needle with the help of a vacuum. Core needle biopsy may cause some bruising but leaves only a tiny dot for a scar. Core needle biopsy may not be suitable for patients who have an irregularity close to the chest wall, the nipple, or the surface of the breast; those with calcifications that require magnification; or women with very small breasts. In these situations, accurate results may not be possible and an open surgical biopsy (see Surgical Biopsy) will be recommended.
Stereotactic core needle biopsy. With this procedure, the mammographer or surgeon looks at a mammogram image while performing the biopsy in order to precisely locate the suspicious area. This method is useful when the doctor can see an abnormality on a mammogram but cannot feel it in a breast exam. The patient lies face down on a specially designed table with the breast compressed. The doctor injects a local anesthetic, makes a 3-mm skin incision, and then inserts the core biopsy needle. Usually results are available within a day or two. Women who cannot remain still for 20–40 minutes because of physical illness or other problems are not good candidates for stereotactic core needle biopsy.
Ultrasound guided core needle biopsy. With this method, the radiologist uses ultrasound imaging to precisely confirm the location for biopsy with the core needle. The doctor makes only a single puncture in the skin to extract three to six separate core needle tissue samples for analysis. The patient may feel some pressure but no pain. The procedure takes only a few minutes. Following the procedure, a bag of ice is placed on the site for 15 to 30 minutes, and most patients are able to resume normal activity almost immediately afterward.
Results of core needle biopsy. In experienced centers, 65% of women who undergo this procedure have a benign diagnosis and can resume having annual mammograms. Another 25% of patients have a malignancy and proceed with treatment.
For the remaining 10% of patients, results are inconclusive. For these patients, the next step is often a type of biopsy known as an excisional biopsy (see Surgical Biopsy). If the core biopsy suggests atypical ductal hyperplasia (see Types of Breast Cancer),surgical biopsy can help determine if the abnormality is atypical hyperplasia (81%), DCIS (13%), or an invasive breast cancer (6%). If, on the other hand, the core biopsy demonstrates tissue changes known as atypical lobular hyperplasia, then excisional biopsy is not necessary because, at worst, the abnormality might turn out to be a noncancerous condition known as lobular carcinoma in situ.
For patients whose core needle biopsy shows DCIS, the full lesion will need to be removed for further examination in the laboratory. For these patients, the likelihood of an invasive breast cancer ranges from 0% to 28%.
Surgical Biopsy
For a surgical biopsy, the surgeon makes an incision in the skin and removes all or part of the abnormal tissue for examination under a microscope. An excisional biopsy is the removal of the entire area of concern, along with a narrow margin of healthy tissue all the way around it. This is done when the abnormal area is small. An incisional biopsy is the removal of a portion of the abnormality and is appropriate for larger lesions in order to secure a diagnosis while minimizing the effect on the breast’s appearance. The procedure can be performed under local anesthesia, intravenous sedation, or general anesthesia, depending on the doctor’s recommendation and your preference. The procedure takes about an hour, and the recovery period is less than two hours.
When a breast mass or an area of calcifications cannot be felt, the surgeon may choose to use a procedure called wire localization to help identify the tissue for later surgical removal. After applying a local anesthetic, the mammographer inserts a hollow needle into the breast and, guided by ultrasound or mammography, locates the suspicious area. The mammographer inserts a thin wire with a hook on the end through the hollow needle and into the breast alongside the lesion. The mammographer then removes the needle, leaving the wire in place to serve as a guide to help the surgeon find the area of breast tissue to be excised later.
When a core needle biopsy is inconclusive, which occurs 10% of the time, a surgical biopsy provides a firm diagnosis. In addition, if a complex cyst does not completely collapse during aspiration, doctors may perform surgical biopsy to find out whether there is a cancer within the cyst.
Unlike needle biopsies, a surgical biopsy leaves a visible scar on the breast and sometimes causes a noticeable change in the breast’s shape. It’s a good idea to discuss the placement and length of the incision with your surgeon beforehand. Also ask your surgeon about scarring and the possibility of changes to your breast shape and size after healing.
In the case of a wire localization surgical biopsy, there is a 2% chance the surgeon will miss the site in question. Of the 20% of women who are diagnosed with cancer following an open surgical biopsy, most require a second breast surgery to make sure all the cancer tissue has been removed along with a safe margin of healthy tissue.
When a breast mass or an area of calcifications cannot be felt, the surgeon may choose to use a procedure called wire localization to help identify the tissue for later surgical removal. After applying a local anesthetic, the mammographer inserts a hollow needle into the breast and, guided by ultrasound or mammography, locates the suspicious area. The mammographer inserts a thin wire with a hook on the end through the hollow needle and into the breast alongside the lesion. The mammographer then removes the needle, leaving the wire in place to serve as a guide to help the surgeon find the area of breast tissue to be excised later.
When a core needle biopsy is inconclusive, which occurs 10% of the time, a surgical biopsy provides a firm diagnosis. In addition, if a complex cyst does not completely collapse during aspiration, doctors may perform surgical biopsy to find out whether there is a cancer within the cyst.
Unlike needle biopsies, a surgical biopsy leaves a visible scar on the breast and sometimes causes a noticeable change in the breast’s shape. It’s a good idea to discuss the placement and length of the incision with your surgeon beforehand. Also ask your surgeon about scarring and the possibility of changes to your breast shape and size after healing.
In the case of a wire localization surgical biopsy, there is a 2% chance the surgeon will miss the site in question. Of the 20% of women who are diagnosed with cancer following an open surgical biopsy, most require a second breast surgery to make sure all the cancer tissue has been removed along with a safe margin of healthy tissue.
