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may be excisional or by needle cytology, but if cytology appears benign and the mass persists, it should be excised
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Figure 16 5 Evaluation of breast masses in postmenopausal women (Adapted, with permission, from Giuliano AE: Breast disease In: Berek JS, Hacker NF [editors], Practical Gynecologic Oncology, 3rd edition, LWW, 2000) Open biopsy under local anesthesia as a separate procedure prior to deciding upon definitive treatment is the most reliable means of diagnosis Needle biopsy or aspiration, when positive, offers a more rapid approach with less expense and morbidity, but when nondiagnostic it must be followed by open biopsy It generally consists of an excisional biopsy, which is done through an incision with the intent to remove the entire abnormality, not simply a sample Additional evaluation for metastatic disease and therapeutic options can be discussed with the patient after the histologic or cytologic diagnosis of cancer has been established This approach has the advantage of avoiding unnecessary procedures, since cancer is found in the minority of patients biopsied for a breast lump In situ cancers are not easily diagnosed cytologically and usually require excisional biopsy As an alternative in highly suspicious circumstances, the diagnosis may be made on frozen section of tissue obtained by open biopsy under general anesthesia If the frozen section is positive, the surgeon can proceed immediately with the definitive operation This one-step method is rarely used today except when a cytologic study has suggested cancer but is not diagnostic and there is a high clinical suspicion of malignancy in a patient well prepared for the diagnosis of cancer and its treatment options In general, the two-step approach outpatient biopsy followed by definitive operation at a later date is preferred in the diagnosis and treatment of breast cancer, because patients can be given time to adjust to the diagnosis of cancer, can consider alternative forms of therapy, and can seek a second opinion if they wish There is no adverse effect from the short delay of the two-step procedure
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compared after accurate staging Various histologic parameters, such as invasion of blood vessels, tumor differentiation, invasion of breast lymphatics, and tumor necrosis have been examined, but they too seem to have little prognostic value Genetic analysis for certain high-risk genes in the primary tumor appears to offer prognostic and therapeutic information The noninvasive cancers by definition are confined by the basement membrane of the ducts and lack the ability to spread However, in patients whose biopsies show noninvasive intraductal cancer, associated invasive ductal cancers metastasize to lymph nodes in about 1 3% of cases
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cancer; to examine the contralateral breast in women with cancer; to examine the extent of cancer, especially lobular carcinomas; or to determine the response to neoadjuvant chemotherapy PET scanning does not appear useful in evaluating the breast itself but is valuable to examine regional lymphatics and distant metastases 5 Cytology Cytologic examination of nipple discharge or cyst fluid may be helpful on rare occasions As a rule, mammography (or ductography) and breast biopsy are required when nipple discharge or cyst fluid is bloody or cytologically questionable Ductal lavage, a technique that washes individual duct systems with saline and loosens epithelial cells for cytologic evaluation, is being evaluated as a risk assessment tool but appears to be of little value
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Bartella L et al Imaging breast cancer Radiol Clin North Am 2007 Jan;45(1):45 67 [PMID: 17157623] Eubank WB et al Evolving role of positron emission tomography in breast cancer imaging Semin Nucl Med 2005 Apr;35 (2):84 99 [PMID: 15765372] Lenahan C et al The role of tumor markers in breast cancer management Curr Surg 2004 Nov Dec;61(6):532 7 [PMID: 15590016]
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