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Breast Cancer Symptoms and Diagnosis    

When breast cancer first develops it is common that there are no symptoms of this disease at all.  There is no pain associated with the early stages of breast cancer.

If any of the below changes occur, you should see the doctor immediately. More than likely you will be asked to have a thorough examination, mammogram and or an ultrasound to help diagnosis what this change might be.

 

As cancer progresses it can cause some of the following:

  • A lump or thickening near the breast or the (underarm area) axilla

  • Size and or the shape of the breast changes

  • Nipple discharge

  • Changes in color of the breast tissue or nipple/areola complex area

  • Skin changes of the breast tissue, areola or nipple/areola complex area - such as dimpled, puckered or a scaly feeling

 

                                   Nipple Changes of the Breast

                                     Copyright 2010 ADAM, Inc. - Used with permission   

                                Image of Nipple Changes  -  Inversion and Crusting

 

 

 

Being pro-active with doing breast exams monthly is of utmost importance.  Especially, if there is any family history of breast cancer.  If you detect any abnormality, a mammogram and a physical exam will be ordered.   If there is any concern with either of those exams, then an ultrasound will be performed on your breast. 

To find out the cause of any unusual signs or symptoms in a woman’s breast, a physician will do a careful physical exam along with asking about personal and family medical history.

 

The doctor may do one or more of the breast exams described below:

  • Palpation a physician can tell a lot about a lump with its size, texture and whether or not it moves easily.  Palpation includes feeling the lump and surrounding tissue around it.  Benign lumps feel significantly different from cancerous ones.

  • Mammography – this is an x-ray of the breast, which gives the radiologist information about the breast lump.  If an area on the mammogram looks abnormal, then additional x-rays are usually needed.

  • Ultrasound – this is high frequency sound waves.  This test shows whether or not a lump is solid or filled with fluid.  Ultrasonography is used along with a mammogram when diagnosing a suspicious area.

 

Imaging tests for diagnosing an abnormal mammogram or a lump:

 

                                   Mammogram vs. MRI - of the breast

                        Image of breast compared with a Mammogram and a MRI

 

 

Depending on the results of the imaging test, the patient will be referred for a breast biopsy.  A Breast Biopsy is the only definitive way to determine whether cancer is present.   Based on the examination of the patient, mammogram and ultrasound test a physician may decide to have a needle aspiration or biopsy performed.  With this test fluid and or tissue is removed from the breast to make a diagnosis.

 

                               Breast Biopsy for breast cancer

                                     Copyright 2010 ADAM, Inc. - Used with permission   

 

 

Different Methods of Breast Biopsy:

 

Doctors determine what method of biopsy based on the following criteria:

  • The shape of the lump

  • The size of the lump

  • The location of the abnormality

  • The number of abnormalities present

  • Patient’s medical history

  • Patient’s preference

  • The training of the radiologist or surgeon who is performing the biopsy

  • The breast imaging center or surgical center

Risks and side effects of a breast biopsy differ on the type of biopsy that is necessary.  Patients should talk with their physician prior to undergoing the procedure about the advantages and disadvantages of each different biopsy offered.

 

 

 

The procedure for a needle biopsy or a fine needle biopsy uses a fine gauge needle (22 or 25 gauge) and a syringe to sample fluid from a breast cyst or remove clusters of cells from a solid mass. 

If a breast lump is felt, the radiologist or surgeon will guide a needle into the area of concern by palpating the lump.  If the lump cannot be felt, the FNA procedure will be done with the assistance of either stereo-tactic mammography or ultrasound with the patient in either in the upright or prone position.

 

                                        Fine Needle Biopsy of the Breast

                                    Copyright 2010 ADAM, Inc. - Used with permission   

 

Aspiration or Needle Biopsy will remove the fluid or a small amount of tissue from the actual breast lump.  This procedure will determine whether a lump is a fluid filled cyst (not cancer) or a solid mass (which may or may not be cancer). The tissue is removed with a needle from an area that is suspicious on a mammogram.

After the needle is inserted into the breast where the abnormality is, a vacuum is created and multiple needle motions are performed. This is done to ensure that adequate tissue is taken for diagnosis at the laboratory.

If tissue is removed in a needle biopsy then the physician or radiologist will want a pathology done on this at a laboratory. If fluid is removed from a cyst, then the fluid may or may not be checked by a lab. 

This procedure is done as an outpatient basis. Fine Needle Aspiration does not require stitches, and a small bandage is placed over the area after the procedure. Fine needle aspiration is the fastest method of breast biopsy with the result available rapidly. This procedure is great for confirming breast cysts.

 

 

 

A core needle biopsy involves removing small samples of breast tissue using a hollow “core” needle.  For lumps that are able to be felt, the radiologist fixes the abnormality in one hand and performs a needle biopsy with the other.  With lumps that are not palpable and cannot be felt, stero-tactic mammography and ultrasound image is used to help determine the exact location of the breast mass based on mammograms taken from two different angles. 

 

                           Ultrasound Assisted Breast Biopsy

        Copyright 2010 - MAYO Foundation for Medical Education and Research - Used with permission

                                        Ultrasound Assisted Breast Biopsy

 

The needle used in a core needle biopsy is a larger gauge than the one that is used for a fine needle biopsy. Normally a 16, 14, or 11 gauge needle is used. This core needle biopsy needle also has a special cutting edge attached to it.

                                            

                                  Core Needle Instruments for a Breast Biopsy

                                                     Core Needle Instruments

 

Lidocaine is used to help numb the area. Anywhere from three to six separate needle insertions are needed to obtain a sufficient sample of breast tissue. Slight pressure is felt during the core needle biopsy. As the tissue is being retrieved, a clicking noise can be heard from the needle and sampling instrument. The average sample size that is retrieved is approximately 2.0 cm. long and 0.16 cm. in diameter is removed. The samples are then sent to pathology for diagnosis.

 

                           Core Needle Biopsy Procedure

                                 Copyright 2010 ADAM, Inc. - Used with permission

                                                  Core Needle Biopsy Procedure

 

Both the core needle biopsy and the fine needle aspiration only removes samples of the actual mass, not the area around the abnormality.  

 

 

 

Vacuum Assisted Biopsy is a new way of performing breast biopsies. The trade name for this procedure is called a Mammotome or a MIBB. This procedure relies on stereo-tactic mammography and or ultrasound imaging to pinpoint the exact location of the abnormality. The vacuum assisted biopsy procedure is done with the assistance of either stereo-tactic mammography or ultrasound with the patient in either in the upright or prone position.

 

                                             Vacuum Assisted Biopsy or Mammotome

                                         Image courtesy of www.imaginis.com

                                         Vacuum Assisted Biopsy or Mammotome                                   

 

This is a minimally invasive procedure that allows for the removal of multiple tissue samples.  Compared to the core needle biopsy which uses multiple needle insertions to acquire one sample  the vacuum assisted biopsy is a unique device only needs to be inserted once into the breast through a small area in the skin of the patient’s breast. If the radiologist needs to examine other areas of the breast, then the probe is rotated moving the sampling chamber 30 degrees to the new position. This entire cycle is repeated until all desired areas have been sampled (which is normally between 8 – 10 samples of breast tissue around the abnormal lump). 

The vacuum line draws the breast tissue through the probe of the device into its sampling chamber. Once the tissue is in the sampling chamber, the rotating cutting device is advanced and a tissue sample is captured. If the patient has more than one abnormality, then in some cases a small sterile clip is placed into the biopsy site of the breast to mark the location in case if a future biopsy is needed. The tiny clip is a “micro-clip” and is left inside the breast and causes no pain or harm to the patient. The samples are then sent to pathology for diagnosis.

 

                                 Vacuum Assisted Biopsy

                                 Copyright 2010 ADAM, Inc. - Used with permission

 

Vacuum-assisted breast biopsy is being more commonly used however; requires a highly skilled radiologist or surgeon to perform the procedure.

Patients will experience some swelling and bruising after the procedure and are instructed to take over the counter pain relief if needed (Tylenol). Bruising occurs during the first five to seven days after the biopsy.  Bruising is temporary and normal after a biopsy.

 

 ADVANTAGES OF VACUUM ASSISTED BIOPSY VS. OPEN SURGICAL BIOPSY:

  • Vacuum assisted biopsies (VAB) are minimally invasive using only .25 inch of an incision site – versus a surgical biopsy that require at least 1.5 to 2 inches for an incision.

  • VAB has little to no scarring - versus a surgical biopsy that might leave a significant scar.

  • VAB is performed under local anesthesia versus a surgical biopsy that might require either local or general anesthesia.

  • VAB requires no stitches versus a surgical biopsy which does require stitches.

  • VAB is performed in less than hour versus surgical biopsy which can take an hour or more.

  • VAB all patients can return to activity immediately versus surgical biopsy which needs a day to recover.

  • VAB cost significantly less than a surgical biopsy.

  • VAB usually provides a definitive diagnosis with the tissue samples collected.  Surgical biopsy does give a definitive diagnosis with the tissue samples.

 

 

 

A large core breast biopsy or Advanced Breast Biopsy Instrumentation; is a surgical technique that involves removing the entire intact breast lump or abnormality under the help of using stereo-tactic mammogram. This method of breast biopsy tends to be less invasive than a traditional open surgical biopsy, but has not gained widespread acceptance because of the controversy of taking a significant portion of normal breast tissue just to reach the abnormality. With surgical biopsy, the surgeon will only remove a narrow small strand of breast tissue in order to reach the lesion. 

Lidocaine is used to numb the breast. A wire is then guided into the breast abnormality using stereo-tactic mammography.  A cannula or the large core needle is then inserted into the breast using the wire as a guide.  The core specimen is removed using a looped wire and then the tissue is sent to pathology.

 

            Large Core Needle Biopsy                  Large Core Biopsy with Wire Localization      

                          Copyright 2010 - Wellness Library @ Mount Nittany Medical Center

                          Large Core Biopsy                   Large Core Biopsy with Wire Localization

 

Critics of this procedure claim that large core biopsy does not take an adequate amount of tissue around the breast abnormality for the laboratory to analyze; however it removes unnecessary normal breast tissue. Large core biopsy can remove 5 mm to 20 mm of breast tissue. The procedure also allows the radiologist or surgeon to remove the entire lesion in one non-fragmented piece. However, some medical professionals question the benefit of this.

Due to the large size of the biopsy section, sutures are required. Also, the procedure takes one hour and is followed by several hours of recovery.

 

 

 

Traditional open surgical biopsy is still considered the “gold standard” to other methods of breast biopsies. Surgical biopsy uses a 1.5 to 2.0 inch incision in the breast. Because of the advancement in technology, there are less invasive biopsy procedures available now such as the Core Needle Biopsy or the Vacuum Assisted Biopsy.

Local, IV Sedation and General Anesthesia are all used for surgical incision biopsy.  However, most are done under local anesthetic. 

During an “excisional surgical biopsy” procedure, the surgeon will try to completely remove the area of concern (abnormality), often along with a surrounding margin of normal breast tissue. If the lump is palpable, it is excised in an uncomplicated surgery which is performed in an operating room.

 

                                  Excisional Surgical Biopsy of the Breast

                                    Copyright 2010 ADAM, Inc. - Used with permission

 

During an “incisional surgical biopsy”, the surgeon will only remove the part of the breast abnormality. The incisional surgical approach is only performed on large abnormalities.

Sometimes the surgeon will use mammography to help locate the area of the abnormality and mark the area with a wire marker, dye, carbon particles or several of these methods. This is commonly referred to as needle or wire localization and is necessary when the abnormality can only be seen on imaging tests. Wire or needle localization is only performed on the abnormalities that cannot be felt. A thin wire is put through the center of the hollow needle to indicate the exact area of removal. There is a hook at the end so the wire will not slip off from the soft breast tissue.  The needle is removed, with the wire in place. The radiologist will then perform a second mammogram to ensure the position of the wire is in the correct area of the breast.

Once inside the operating room the surgeon will remove the wire and the surrounding margin of breast tissue. A set of x-rays are taken of the removed specimen with the wire. Another set of x-rays are taken of the breast to confirm the area in question was in fact removed. Once this is finished, the specimen is sent to pathology for a diagnosis.

The incision is closed with suture material. The surgeon will either use dissolvable sutures or permanent sutures. If dissolvable sutures are used, the sutures material will absorb and dissolve in the body on their own within 60-90 days. There is no need for removal with dissolvable sutures.  If permanent sutures are used, then the patient needs to have these removed within a week. The scar from a surgical biopsy is normally small.

 

Open surgical biopsy can possibly alter the shape of a woman’s breast on the following factors:

  • The size of the breast abnormality

  • The location of the breast abnormality

  • The amount of surrounding breast tissue that is removed in addition to the abnormal lump

 

ADVANTAGE OF OPEN SURGICAL INCISION BIOPSY

A surgical biopsy excises the largest breast tissue sample compared to all the other breast biopsy methods.  The accuracy of the diagnosis using the open surgical method is close to 100%, making it the “gold standard” of breast biopsy methods.

 

                                        Surgical Excision of the Breast

                       Copyright 2010 - Wellness Library @ Mount Nittany Medical Center

                                                  Surgical Biopsy of the Breast

 

DRAWBACKS OF THE OPEN SURGICAL INCISION BIOPSY

Disadvantages of the Open Surgical Incision Biopsy:

  • Incision requires sutures and can leave a scar

  • Scar formation within the breast can persist for a year or longer, and can interfere with future mammograms

  • Bleeding

  • Infection

  • Wound healing

  • Risks with anesthesia

  • Chance of a piece of the localizing wire break off deep within the breast

 

 

 

If the diagnosis is cancer, the pathologist will be able to tell what kind of cancer it is.  Breast cancer either starts out in a duct or a lobule.  The pathologist will also be able to tell whether the cancer is invasive and if it has in fact invaded nearby tissues of the breast of lymph system.  If a spot is detected in the lymph nodes, a biopsy of this area will be done as well.

 

                           Diagnosing Breast Cancer

                                          Copyright 2010 ADAM, Inc. - Used with permission

 

                                         Sentinel Lymph Node

                                         Copyright 2010 ADAM, Inc. - Used with permission

                                                              Lymph Node Biopsy

 

 

 

Hormone receptor tests are done to see if the cancer is estrogen and progesterone receptor positive.  If the results are positive for these hormones, it means that these actual hormones contribute to the cancer growth and more than likely will respond to hormonal therapy.  Other lab tests are done to see if the cancer is likely to grow slowly or quickly.

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More Breast Reconstruction and Breast Cancer Information:

 

 

   

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