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Diagnosis

How Is Breast Cancer Diagnosed?

There are several imaging tests used to diagnose breast cancer. BMC’s Belkin Breast Imaging Center, designated a Breast Imaging Center of Excellence by the American College of Radiology, offers patients a full range of diagnostic services. A diagnostic work-up may include one or more of the following tests:

Mammogram

A mammogram is an x-ray of the breast that uses a small amount of radiation. A technologist will position your breast for the test. The breast will be compressed between two plates, and a picture will be taken. Compressing the breast flattens and spreads the tissue, providing a clearer picture of the inside of the breast, making it easier to detect any changes. The technologist will then reposition the breast and the plates for a second picture. The entire process takes about twenty minutes.

Breast MRI

Magnetic resonance imaging, or MRI, uses magnets and radio waves to make very precise cross-sectional pictures of the body. For breast MRI, you will lay face-down in a narrow tube with openings for your breasts. These openings allow the imager to take photos of the breasts without pressing on them. The process can take up to an hour. You may be injected with a contrast material to improve the quality of the images. To ensure the quality of the images, it is very important for you to remain still for the duration of the process.

Breast Ultrasound

Ultrasound uses sound waves to produce an outline of part of the body. A computer picks up the echoes from the sound waves and uses them to generate a picture on the computer screen. For breast ultrasound, a small, microphone-like instrument is placed on top of the breast after it is covered with a special type of gel that allows the sound waves to pass directly from the instrument to the skin. Breast ultrasound is particularly useful in determining whether something is fluid-filled (a cyst) or a solid mass (a tumor).

If an abnormality is found, the only sure way to know if it is cancer is to examine the tissue directly. This is done by removing a sample of tissue from the breast and sending it to a pathology lab to have it examined under a microscope. The removal of cells or tissues for examination by a pathologist is called a biopsy. In all biopsy procedures, the area being biopsied is numbed and/or the patient is sedated to minimize any pain or discomfort. Types of biopsies include:

Fine Needle Aspiration (FNA) Biopsy

FNA uses a thin, hollow needle (thinner than the needles used to draw blood) to draw out fluid or tissue from a lump. Depending on the size and location of the lump, the needle is sometimes directed into the lump simply by feeling it. Other times it may be guided into the lump with the assistance of an ultrasound. FNAs are rarely painful and don’t tend to leave scars. Although FNA is the easiest type of biopsy to have, it doesn’t always provide a clear result.

Core Needle Biopsy

A core needle biopsy uses a thick needle to draw out cores (pieces) of tissue for examination. Because the thicker needle is able to remove more tissue, a core needle biopsy is more likely to provide clear results than a fine needle aspiration.

Vacuum-Assisted Biopsy

Vacuum-assisted biopsies are done using Suros technologies with the assistance of a mammogram, MRI or ultrasound. A small cut is made in the skin after it has been numbed. A hollow probe is entered through the cut and a piece (or several pieces) of tissue are removed. Vacuum-assisted biopsies generally remove more tissue than core needle biopsies. The medical term for this type of biopsy is a stereotactic biopsy.

Surgical (Open) Biopsy

The least common type of biopsy, a surgical (or open) biopsy is generally used to remove all or part of the lump for examination under a microscope. When the whole lump is removed, the surgeon may also remove some of the surrounding healthy tissue. Surgical biopsies are generally performed in the hospital’s outpatient centers. Local anesthesia is used in combination with other drugs to make you relaxed and drowsy. The procedure can also be done using general anesthesia.

Lymph Node Biopsy Breast Cancer

Often done at the same time as the breast biopsy or at the time of surgery, a lymph node biopsy uses a needle to remove entire lymph nodes for examination under a microscope.

Once removed, pathologists perform a thorough examination of the sample tissue. If the tissue is cancerous, it is given a grade from 1 to 3. A low grade (1) indicates the cancerous tissue has an appearance similar to that of regular tissue. Lower grade cancers tend not to grow as quickly as higher grade cancers. Grade is useful in predicting prognosis (outcome).

Pathologists also test cancerous tissue for hormone receptors: proteins in cells with the ability to attach themselves to hormones in the blood). Estrogen and progesterone are naturally occurring hormones in women’s bodies that can attach to receptors in some breast cancer cells and fuel their growth. If estrogen receptors are present in a tumor, it is called estrogen receptor-positive (ER-positive). If progesterone receptors are present, the tumor is progesterone receptor-positive (PR-positive). If both receptors are present, it is referred to simply as hormone receptor-positive. At least one of these receptors is present in approximately 2 out of 3 cases of breast cancer (American Cancer Society, 2015b). Hormone receptor-positive cancers tend to be slower growing and generally respond well to hormone therapy.

Cancerous tissue is also tested for too much of a protein called HER2/neu. Cancers with high levels of HER2/neu are called HER2-positive. Approximately 1 out of 5 breast cancers are HER2-positive (American Cancer Society, 2015b). These cancers tend to grow and spread quickly and are treated with drugs specifically targeting the HER2/neu protein.

Certain cancers, when tested, are neither hormone receptor-positive nor HER2 receptor-positive. In other words, the cancer cells do not possess estrogen receptors or progesterone receptors, and they do not have high levels of HER2/neu. These cancers account for approximately 15 out of 100 cases of breast cancer and are called triple-negative breast cancers (National Cancer Institute, 2012).

Once a woman has been diagnosed with breast cancer, there are several ways to find out if the cancer has spread. These include:

Chest X-ray

Chest x-rays provide an image of the heart, lungs, airways, blood vessels and bones in the spine and chest area. They can be used to look for broken bones, diseases like pneumonia, abnormalities, or cancer.

Bone Scans

Bone scans involve a low dose of radioactive material that is injected into a vein. Bone attracts this material. Concentrated areas show up on the scan and are referred to as "hot spots." Hot spots may be indicative of a variety of diseases and conditions.

Computed Tomography (CT) Scan

CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut. Doctors order CT scans when they want to see a two-dimensional image of the body to look for tumors and examine lymph nodes and bone abnormalities. If contrast dye is used to improve the computer image, the patient may need to avoid eating or drinking for 4 to 6 hours before the test. Patients should tell their provider before the test if they have any allergies or kidney problems.

Magnetic Resonance Imaging (MRI)

This test uses a magnetic field, radiofrequency pulses, and a computer to produce detailed images of body structures in multiple places. You may be asked to drink a contrast solution for better imaging, and you will most likely lie on a moving table as pictures are taken. MRI is a more detailed tool than x-ray and ultrasound and for certain organs or areas of the body, it provides better images than CT. MRI may not be recommended if you have a pacemaker or other metal implant.

Duplex Ultrasound

A painless procedure where gel is placed on affected area and a handheld device is moved across it in order to obtain a picture of the blood flow in the body,

Positron Emission Tomography (PET) scan

A PET scan is used to detect cellular reactions to sugar. Abnormal cells tend to react and "light up" on the scan, thus helping physicians diagnose a variety of conditions. For the PET scan, a harmless chemical, called a radiotracer, is injected into your blood stream. Once it has had time to move through your body, you will lie on a table while a scanner follows the radiotracer and sends three-dimensional images to a computer screen. Patients are generally asked to wear comfortable clothing and refrain from eating for 4 hours before the scan. Tell your doctor if you are pregnant or breastfeeding. Patients with diabetes should discuss diet guidelines with their physician for the hours leading up to the scan.

Based on the findings of a patient’s diagnostic work-up, he or she may meet with BMC experts in a variety of specialties including internal medicine, medical oncology, pathology, radiation oncology, radiology/mammography, and surgical oncology.

The results of these consultations and procedures are reviewed in the Cancer Care Center’s weekly multidisciplinary Breast Tumor Board meeting. Each patient receives a comprehensive, individualized care plan, designed to meet their specific needs. Following this review, the patient’s BMC physician will discuss the Tumor Board’s recommendations with the patient and her family, and together they will develop a comprehensive treatment plan.

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