Breast Cancer Diagnosis

When the tissue sample is inspected grossly, the tumor is measured in three dimensions using a ruler and the distance to all the margins of excision are recorded. Other observation such as the presence of satellite nodules, tumor necrosis (death tissue), calcifications, relationship with the skin, nipple or deep fascia etc are recorded. The presence of other possible non-cancerous lesions are described. Ultimately, samples of the tumor, margins, other lesions etc. are taken and submitted for microscopic examination.

There are multiple parameters used to determine the tumor aggressiveness. Some are histological, some molecular some clinical.

The histologic indicators are: tumor size, tumor histology, tumor differentiation, lymphovascular invasion, multi-focality, and number of mitosis.

Molecular parameters include expression of estrogen and progesterone hormonal receptors; expression of HER2-neu; proliferative activity of the tumor (Ki67, mitosis) and other genetic profiles of the tumor cells as determine by molecular analysis of the cells via RNA or DNA studies such as Oncotype, Mamotomme etc. that provide a “genetic signature” of the tumor cells able to predict the aggressiveness of the tumor and guide to a certain extent the therapeutic approach.

Clinical parameters relate to the clinical and imaging findings such as palpable lymph nodes, positive scans for probable metastasis, etc.

Smaller and single size (<2 cm) tumors with pure mucinous or tubular type of histology or other histology that is well differentiated (grade 1), with no vascular/lymphatic invasion, and ER/PR positive with no overexpression of Her2 neu would be the least aggressive tumors. However, the histologic/molecular parameters are secondary to the stage of the tumor as given by the TNM staging.

Cancer staging system is routinely used to summarize some histologic/clinical characteristics of the tumors. The staging includes three letters: T is for Tumor size; N is for lymph Node metastasis and M is for distant organ Metastasis. Of the four possible stages, Stage 1 will have the best prognosis since the tumors in this group are small and there is no nodal or distant organ metastasis. It is only within the same stage that the histologic and molecular indicator acquire larger relevance.

Basic starting points would be listening to the patient, breast examination and appropriate imaging. It is recommended that an image-guided biopsy be done (either stereotactic or ultrasound-guided), rather than an excisional biopsy operation. Fine needle aspiration can be performed as an alternative, but the core biopsy yields more information.

If the target for biopsy is microcalcifications, the adequacy of the specimen can be confirmed by doing a modified mammogram on the obtained specimens, to make sure that calcifications are within the tissue being sent to the pathologist. For masses and other types of biopsied lesions, it’s a bit trickier. For all biopsies, the amount of tissue collected can be visually assessed by the doctor performing the biopsy. For ultrasound-guided biopsies, the needle can be seen in real-time on the screen, and the doctor can see the biopsy needle going through the sampled lesion. For an MRI-guided biopsy, the MRI images taken with the biopsy needle in position are important for confirmation of appropriate tissue sampling. Knowing that there is always room for sampling error by the needle, most radiologists recommend six-month follow-up imaging of the biopsied breast, to confirm that the area biopsied has not changed in any significant way. In addition, when the radiologist receives the pathology report from the biopsy, he/she decides if this result from the pathologist is “concordant” with the imaging findings. If the pathology is not an acceptable answer for the radiologist’s findings (discordant), the radiologist will recommend that the lesion be taken out surgically to confirm benignity.

For almost all findings found by imaging (mammography, sonography, or MRI) a needle biopsy is the preferred next step. Firstly, most of the findings (nodules and calcifications) which we identify are benign, so surgery can be avoided. Sometimes we are quite certain that the finding is malignant but still a needle biopsy is performed so that the surgeon performs surgery knowing what s/he is going after. For example, if the surgery is removal of a biopsy-proven cancer (lumpectomy) then they should remove larger margins. In this day and age it is fairly unusual to go to surgery to remove a nodule that the surgeon does not know what it is. Furthermore, if the diagnosis of cancer has been established in advance, then the surgeon will do the evaluation of axillary lymph nodes (sentinal node biopsy) at the time of the initial surgery (a one-step procedure). Also, they will be planning for the best cosmetic result.

When a lump is felt, but no abnormality is identified on imaging studies, a surgeon may still opt to remove it. In that scenario s/he does not know what they will find at surgery. A needle biopsy may or may not be done first. If a needle biopsy is being done, it is based on the palpable finding (feeling the lump) this would be done by the surgeon, not the radiologist.

What about BSGI or PEM? Are you talking about what if the DCIS is generalized or contained in one spot?

Jamie, I'd like to add to your wonderful insights here. Adults sometimes hide their diagnosis because of their own experience with cancer. If they grew up with a parent going through cancer, treatments and outcomes were very different 20, 30 or 40 years ago. And if it wasn't discussed, the underlying message absorbed was, "cancer isn't something we talk about." As irrational as it sounds, it might seem easier not to talk about it. Sharing with others, especially children can be overwhelming especially when you're struggling to wrap your own mind around it. Yet, if it's not talked about children will often imagine what's wrong...as you noted they sense the unspoken. The trouble with "imagining" what's wrong is that it can lead to false conclusions, doubt and even shameful feelings. Children may think that they're somehow responsible for what's wrong in the family. It's also not uncommon for children to have drastic thoughts such as "is my mom going to die." It's a common fear that passes through adults minds, and children are no different. Cancer won't get worse by talking about it! Children (at all ages) respond well to visuals, hence picture books are very helpful. Books also afford a platform to journey through difficult emotions together. Children are the focus of all the tough topics I write about. They are alongside the adult making the journey, so it's imperative that they be included as helpers and encouragers. Equipping them with understanding on their level (as you noted) is a life-long gift for patient and child. Thanks Jamie. ---
Maryann

Unfortunately, this is most likely consider as a stage IV. It is very important that you seek second opinion at Breast Center specializing in inflammatory breast cancer such as at MD Anderson Cancer Center and/or Phase I/II program that provide multiple clinical trial options. As long as feeling well, there are many choices to explore.

This is a critical question. I found that the medical care and treatment were outstanding but that the "soft"side was not so much in place. I connected with 2 other women who had been diagnosed at a similar time and who were also treated in the same hospital. This was invaluable and we are still in contact and now try to ensure that our checks coincide.

To be absolutely honest though, a significant support network was online. I subscribed to two Breast Cancer sites, one UK and one US based. On one site I followed a thread of women who were going through chemotherapy at the same time and although we were at opposite sides of the planet our side effects brought us together. I was able to share highly personal details with a group of women, many of whom I did not know their name!

I also blogged throughout the experience (and still do). This was a great way of communicating what was happening to friends and family far away. However more than this, it enabled me to process everything I was going through. I also find that it has provided a detailed record and document of the experience. It was an important coping strategy.

There were distinct advantages of having my treatment overseas. I was able to continue working, for example. I had virtually no waiting time for treatments and had access to top medical care and facilities. As I mentioned earlier, the gap was on the support and "soft" side and I had to make more effort in this area to find the support I needed.

I have to say that during the whole treatment period I had the support (physical, emotional and practical) of my husband who was at my side throughout.

I think it was probably harder for my family than it was for me being overseas.

Inflammatory breast cancer is suspected when you have a very red breast, the breast will become big, and this will happen within one to two month. Sometime it could be faster. You do not have to feel a mass. Therefore, it is commonly misdiagnosed as mastitis (infection of the breast). The only way to make the diagnosis of the IBC is to have a biopsy and look under the microscope. Combination of the biopsy and clinical presentation confirms the diagnosis of IBC.

Since inflammatory breast cancer grows in sheets or nests in the lymphatic layer of the skin, that puts it at a stage III B at diagnosis. If the cancerous cells (or tumor cell clusters) aren't in the lymphatic system to cause the visible skin changes, it isn't inflammatory breast cancer (IBC). IBC is diagnosed at stage III B, III C, or stage IV, depending on the extent of spread in the body.

The only true "early detection" for IBC is to be aware of breast changes. Look in the mirror regularly and look for differences. If you notice rapid increase in breast size, change in the color and/or texture of the breast skin, pain or itching of the breast, warmth or a heavy/full feeling in the breast, or other significant breast changes that don't resolve in 2 weeks it is time to see your healthcare professional. These symptoms can be the result of infection but if the symptoms aren't resolved with 7-10 days of antibiotic it's time to see a breast specialist to rule out IBC with a biopsy.

I find Attai's very interesting. I was referred to a breast surgeon by a Dr of Radiology. My breast surgeon told me flat out "you will need surgery for sure" and then she did the surgery. She is a past President of ACS in my area and one of the doctors on the board of directors at the hospital I had the surgery at. It confuses me to see a statement "Once cancer is diagnosed, the breast surgeon will work with the medical oncologist and radiation oncologist as a team to decide in a multidisciplinary fashion what the best treatment is. " It makes me feel that I am having treatment done backward. I don't know. I return to the surgeon on the 30th (my lumpectomy was done on the 19th). The tumor is stage 2A. No spread to the nodes. I have to wonder how my treatment is going to be handled. I don't think the surgeon will be dishing out what a radiology oncologist is supposed to be doing. This surgeon also said she believes I will NEED chemo. I am not accepting that yet. I did find out about Oncotype DX which will help with MY decision to go ahead with chemo or not. I am just confused about what Dr Attai says here. I need to know that I am on the right road to recovery.

Our boys were 3 and 4 at the time. We chose not to say anything until we knew more about the plan for treatment. However, children are very intuitive. Before we told them, by four year old began asking questions. "Mommy, is one of your friends sick?" No dear.
"Is one of your friends dying?" No dear. I could tell he was affected by all the hushed conversations. When we did tell them, we explained that mommy had some stuff inside her that was making her sick and the doctor needs to take it out. The 4yr old had had some minor surgery the year prior. He asked me if I would be going to the same hosp, i said yes, He asked me if the doctor would use the same tools. I said yes. He then looked at me and said, "Oh, then you will be fine." and scampered off. When I came home, he helped with the drains, and it made him feel so important. The younger one really did not comprehend any of this, and neither remembers anything. I never said the word cancer. At the time, my mother was losing her battle, and died seven months later, and my older son's best friend's mother was losing her battle. We feared that if the boys knew I had cancer, they would think I would soon die. I would not change the way I handled it, except maybe to tell them at least something right away. I am sure the wheels were going in their heads and likely this caused some stress.

Despite recent claims, there is no 3D imaging yet available. Tomosynthesis (aka “tomo”) is about "2.5D" looking at the breast in a 270 degree arc but not 360 degrees. Tomo requires about 8 films and does require compression. It does give a better look at the markedly dense breast. It should not become the "routine screening" for all women. At UMass Memorial, we have been awarded a federal grant along with four other centers in the United States to build and pilot CT scanning for the breast. Our initial work with a home built unit and mastectomy specimens was highly successful leading to the grant award. CT scanning is truly 3D with 360 degree views without compression, faster times and more views. Radiation exposure should be equivalent to Tomo. We have raised over $500,000 to build and install our breast CT unit within the year. Again as with tomo, breast CT is not at this time meant for routine screening.

Screening mammograms check for lumps in the breast when there no signs or symptoms of breast cancer. Two X-rays are taken of each breast to determine if there have been any tissue changes compared to previous mammograms and look for tumors and microcalcifications.

Diagnostic mammograms are used to help diagnose or rule out breast cancer. Diagnostic mammograms are given after a lump or other sign or symptom of the breast cancer has been found. For diagnostic mammograms, more x-rays are taken to obtain views of the breast from several angles. Suspicious areas may be magnified to produce a detailed picture. The purpose is to locate and analyze potentially cancerous tumors or cells.