Breast Cancer Diagnostics
Pune Breast Care
The first step in making a sound treatment strategy for breast cancer, involves accurate diagnostic tests and complete information gathering. At Pune Breast care, we help you expedite the diagnostic process, but ensuring accuracy at every step. We take the time to explain your diagnosis in detail to to help you make a better treatment plan and feel prepared and confident in the journey.
Investigations for Breast Cancer
A diagnostic mammography is different from a screening mammogram done for healthy women. Special magnification and compression views may be used in this mammogram to study the affected area in detail. The mammogram helps the surgeon to determine if there is one tumor or more and also whether the opposite breast is normal. It can show suspicious calcifications that may indicate pre-cancerous tissue (DCIS) in surround tissue.
Dr Pranjali Gadgil performs her own ultrasounds to evaluate the tumour and plan the surgical approach. The ultrasound confirms whether the remaining breast tissue is healthy. A detailed evaluation of th the nodes in the armpit give an idea of stage of the cancer and helps treatment planning.
Diagnostic Breast Ultrasound
Core Needle Biopsy
A core needle biopsy is the most appropriate way to biopsy a suspected tumor. We perform most of our biopsies under ultrasound guidance for higher accuracy. If there are other abnormal areas on ultrasound, these can also be biopsied even if they are not felt by hand. If the nodes in the armpit appear suspicious, we may biopsy them at the same time as the tumor biopsy, so we can get additional information about the stage of the cancer and plan treatments accordingly.
PET- CT Scan
PET CT:: In late stages breast cancers can spread to bones, liver, lung, brain and other organs. A PET CT scan evaluates the body for spread of breast cancer into these organs. A PET CT scan is performed in a nuclear medicine lab. A glucose containing contrast agent is given intravenously. Areas of the body that show a high uptake of glucose, light up on PET scan, suggesting possible involvement with breast cancer. A PET CT scan is not recommended in staging early breast cancer. Probability of this distant spread in such cases is low and PET CT can show “false positive” findings.
Breast MRI: MRI is performed using specialised equipment in breast-imaging centres. We use this test selectively in cases where mammography may not be adequate for surgical planning. This is particularly helpful in young women with breast cancer, dense breasts and women with BRCA gene mutations.
Types of Breast Cancer
The pathology reports obtained at biopsy can be used to classify the breast cancer based on different criteria
Cell of Origin of the Breast Cancer
80% of breast cancer originates from milk ducts- small tubules that carry milk from milk glands to the nipple. When cancer cells are limited to the inside of the ducts, it is called DCIS or "Ductal Carcinoma in situ". When they are present outside the ducts, it is called "Invasive Ductal Carcinoma" or IDC.
This 2nd most common type arises from lobules of the milk producing glands. It accounts for 10-15 % of all breast cancer.
Less Common Types
Others: Mucinous, papillary, tubular carcinomas, phyllodes tumors, breast sarcomas, breast lymphomas.
Grade of the tumor
Grade indicates how different a tumor cell looks from a normal cell and indicates growth rate. Grade of a tumor does not refer to stage.
Grade I or low grade tumors
These are usually slow-growing and resemble normal breast cells.
Grade II or intermediate grade tumors
These are the most common type
Grade III or high grade tumors
These tend to have a faster growth rate
Molecular Subtype (ER/PR/HER2)
Molecular (IHC) tests done on the biopsy sample include ER, PR, HER2. Prognosis and Treatment of Breast cancer is largely determined by these molecular markers.
Hormone Receptor Positive breast cancer
ER and/or PR positive ( ER+ PR+) tumors are sensitive to and grow under influence of estrogen and progesterone hormones. These tumors can be treated by blocking in the influence of the these hormones with endocrine therapy. ER + PR + HER2 -ve Tumors can be further described as "Luminal A" or "Luminal B"
HER-2 positive breast cancer
HER 2 is a growth promoting protein, seen on lining of this type of tumor. Tumors overexpressing HER2 tend to be aggressive. However treatments available that specifically block this protein to inhibit growth of these tumors. This is called HER-2 targeted or anti-HER2 therapy.
Triple Negative breast cancer
This type of tumor shows neither the ER PR hormone receptors, nor the HER 2 protein on the cell linings, hence it is called ‘triple negative’. Triple negative breast cancer is usually treated with chemotherapy.
Cancer Diagnostics FAQs
Should I get a second opinion on my biopsy report?
Every pathology report should be compared with your physical exam as well as radiological reports. This step called establishing radio-pathological concordance, should be done by an experienced breast specialist. In cases where pathology reports are consistent with radiological findings, a second opinion is usually not required. If the findings are discordant eg if the radiological picture is suspicious, but the biopsy report does not show malignancy you may be advised a review of the biopsy blocks by a different pathologist or a re-biopsy.
Do all breast cancer cases need a PET-CT?
A PET-CT evalautes distant spread of breast cancer. It is usually advised in larger tumors, aggressive tumor types or tumors that have spread to the lymph nodes.It is helpful to study extent of disease in metastatic stage 4 disesae as well. In early breast cancer, the possibility of finding distant spread is very low. The risk of PET-CT scans is that they may show 'false positive' findings ie areas that appear suspicious on scans but do not represent cancer. This may lead to unnecessary biopsies and delay in treatments.
Can a breast cancer spread due to a breast biopsy?
No, it is a common myth that a needle may disturb tumor cells and cause them to spread. This myth has been dispelled by several studies. If cancer cells get displaced into the surrounding environment they do not remain viable to implant. In fact patients who have cancer diagnosed on needle biopsy have better survival outcomes than women who directly undergo surgery.
Why do I need mammography and ultrasound?
Mammography and Ultrasound are complementary exams. Some information obtained on mammography cannot be obtained on ultrasound and vice-versa. For instance, calcifications are seen better on mammography whereas lymph nodes are better evaluated on ultrasound. So women over 40 years of age often need both tests to complete an accurate diagnostic workup for a breast mass.
Should I undergo FNAC or core/trucut biopsy?
FNAC only samples a few cells from a breast lesion. Often sampling is inadequate or yields only blood cells or fat. Reports may describe abnormal cells (atypia) which may ot may not represent cancer. FNACs can also cause higher number of 'false negative' reports which can cause delay in diagnosis and treatment. A core needle biopsy which samples pieces of tissue instead of cells, gives a higher accuracy of diagnosis. The procedure is done under local anesthesia in the clinic without necessitating surgery for diagnosis. We hence prefer core biopsy over FNAC.
Is genetic testing helpful after a cancer diagnosis?
You should undergo genetic counselling to see if you may benefit from genetic testing. A diagnosis of a harmful mutation (eg BRCA positivity) might impact how we treat your cancer. It could a make a difference in the type of surgery as well as chemotherapy that is used in your treatment. Read more about genetic testing here
Why not just remove a lump to get a diagnosis?
“Excisional Biopsy” i.e. removal of a breast lesion as a first step in diagnosis is a very common but wrongful practice. Diagnosis of most breast problems can be made with a high level of confidence by performing a core-needle biopsy under local anesthesia in the OPD. 1)Several breast problems may not need surgery at all, and a needle biopsy can avoid unnecessary surgery.
2)If you have cancer that is picked up on excisional biopsy, you’ve undergone incomplete surgery. This is because a cancer operation involves more than just removal of a lump. Repeat surgery is needed to obtain clean margins and for lymph node staging.
3)If your tumour would have benefitted from chemotherapy to shrinking it prior to surgery, this opportunity is lost.
4)Scars from the excisional biopsy may not allow skin-preservation and optimal aesthetic outcomes at the subsequent cancer operation.
For all these reasons, a needle biopsy should be done first. Surgery should be performed only if it is actually required at all; and the right operation should be performed knowing what the diagnosis we intend to treat.
Can a breast MRI help me?
A Breast MRI is helpful in some cases of breast cancer. In young women with dense breasts, mammography may not describe the complete extent of disease. We often use MRI when planning breast cancer surgery for women less than 40 years of age. MRI is also helpful in occult cancers i.e. when tumor is seen in the lymph nodes but not in the breast. Paget's disease which is special type of cancer of the nipple, is another area where we use breast MRI. We also use Breast MRI for women with genetic predisposition to breast cancer eg BRCA positive cases.
What tests might help me avoid chemotherapy?
Genomic risk assays can be performed on certain types of breast cancer. If a tumor is small, has not spread to the lymph nodes and is ER+PR+ HER2 negative subtype, these tests can be used to classify a tumor as high risk or low risk for recurrence. In low risk groups, hormone therapy alone for 5-10 years may be sufficient and chemotherapy may not add any benefit.
How long can I wait for surgery after diagnosis?
Once a diagnosis is made, patients believe there is a need to rush to surgery. However it is important to gather adequate information on the tumor to make a proper treatment plan. Obtaining molecular details on the tumor, information on disease stage, as well as optimising the patients fitness for surgery may take a few weeks. Several studies have shown that waiting 4-6 weeks to schedule surgery does not advance the stage of most breast cancers. However we usually advise to not delay surgery once the information gathering and surgical planning is complete.