Diagnostic Modalities in Breast Cancer

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Diagnostic Modalities in Breast Cancer

• Kate Stringer 1.3.2005

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Breast Cancer

• Most commonly diagnosed cancer in women
• Excluding BCC and SCC
• Leading cause of cancer death in Australian women
• Incidence 1 in 11
• 1400 women are diagnosed with breast cancer in
  Qld each yr
• 70 of these gt 50yo
• Introduction of screening MMG has reduced
  mortality by 25-30 through early detection

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Diagnosing Breast Cancer

• Triple Assessment maximises sensitivity of
  diagnosis
• Clinical - history and examination 50-85
• Radiology MMG /- USS 90
• Pathology FNA or core biopsy 91
• Sensitivity of triple assessment 99.6 and
  specificity 93
• Triple Assessment is positive if any of above is
  positive but negative when all three negative

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Aims of Triple Assessment

• Maximise diagnostic accuracy in breast cancer
• Maximise preoperative diagnosis in breast cancer
• Minimise excisional biopsies for diagnosis
• Minimise proportion of benign excision biopsies
  for diagnosis

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Clinical - History

• Symptoms
• Mass, discharge, change in breast size, pain,
  axillary lump, skin changes, nipple inversion
• Evidence of metastases eg wt loss, bone pain,
  SOB, symptoms of hypercalcaemia, abdominal
  distension, jaundice, altered cognitive function

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History (2)

• Examine risk factors
• Gender
• Previous breast cancer
• Age
• Family history
• Breast or ovarian cancer in 1st or 2nd degree
  relatives
• Particularly if breast cancer bilateral or
  diagnosed at early age
• BRCA1 or 2 gene mutation RR 8-9, 1-2 of all
  breast ca
• Ataxia telangiectasia heterozygotes are at
  4-times increased risk.
• Race
• Ashkenazi Jewish descent - 2-times greater risk.
• Japanese and Taiwanese woman have one fifth the
  risk

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History (3)

• Increased endogenous oestrogen exposure
• Early menarche, late menopause
• Nulliparity
• HRT
• Risk increased by 30 and this risk increases
  with duration of exposure
• Normalises after 5 years of discontinuance
• Oestrogen and progesterone worse than oestrogen
  alone with 5 years exposure
• Oestrogen 1.05 1.16 RR
• Oestrogen and Progesterone 1.24 1.45 RR
• Increases breast density reducing effectiveness
  of MMG
• OCP

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History (4)

• Personal history of breast disease
• ADH, ALH
• Obesity
• Alcohol
• Irradiation

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Clinical - Examination

• Both breasts
• Inspection -
• sitting, arms above head, on hips tensing
  pectoralis
• size, asymmetry, skin dimpling, nipple
  retraction, inversion, or excoriation (Pagets),
  visible lumps or ulceration, peau dorange
• Palpation - sitting and supine
• Features of breast cancer solitary, hard,
  irregular, immobile and nontender
• Lymph node evaluation
• axillary, supraclavicular
• General examination including abdomen

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Imaging - MMG

• MLO and CC views /- lateral views, coned or
  magnified views
• Cardinal features of malignancy
• Mass spiculated, irregular margins
• Architectural distortion
• Microcalcification with casting or irregularity
• Clustered polymorphic calciification most common
  finding
• Asymmetry
• Sens 63-95 (95 in palpable lesions)
• Spec 14-90

 
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Imaging - Ultrasound

• Characterise mammographic abnormality
• Reliable assessment of tumour size
• Particularly useful in dense breasts
• First line for a palpable lesion in young pts
• Differentiate solid from cystic
• Features of malignant lesions
• Angular and poorly defined margins
• Spiculation
• Shadowing
• Branch pattern
• Duct extension
• Microlobulation
• Height greater than width
• Hypoechoic
• Calcification
• Sens 68-97 Spec 74-94

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• Imaging problems
• MMG underestimate DCIS
• Both modalities can miss lobular carcinoma

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Imaging - MRI

• Sens 88-99 Spec 67-94
• Specific advantages
• May detect lobular ca where other radiology is
  benign
• Sensitive for multifocal disease
• Investigation of pts with implants
• However
• 10 times more expensive than MMG
• Limited availability
• High false positive rate
• Does not reduce need for biopsy
• Less sensitive for DCIS

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Pathology - Fine Needle Aspiration

• Cytological diagnosis
• Can determine hormone receptor status
• Indications
• Palpable lesions done in clinic
• Cystic lesions
• Core biopsy not available
• Impalpable lesions via USS or MMG localisation
• Easy technique
• Requires cytopathologist for evaluation
  preferably on site to ensure specimen adequate
• Results within few hours

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FNA Results

• Insufficient cells in 10-26
• False positive 1-2
• False negative 5-14
• Findings
• Normal tissue or fibrocystic disease core or
  open biopsy if concerns for malignancy
• Benign lesion eg fibroadenoma clinical follow
  up
• Non diagnostic rpt FNA or core biopsy
• Wont distinguish DCIS from invasive ca
• Before definitive surgery, result needs to
  correlate with clinical findings and imaging

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Pathology Core Biopsy

• Histological diagnosis
• Tru cut large bore needle
• 14G needle on a spring loaded biopsy gun, core
  samples under LA
• Obtain 4-6 cores
• Sensitivity 90-95 and specificity 95-98
• Depending on number of cores
• Where possible the tract of the core biopsy
  should be able to be included in excision

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• Indications for core biopsy
• Calcification on MMG particularly without mass
  lesion
• Inconclusive FNA (atypical or suspicious)
• Discrepancy between FNA and clinical /
  radiological features
• Advantages over FNA
• Reduced number of inadequate specimens
• Tumour grading, tumour typing, may distinguish
  between DCIS and invasive ca, assess lymphatic
  invasion, more tissue for hormone receptor status
• FNA requires experienced cytopathologist

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Impalpable lesions

• Majority of screen detected lesions
• 15-30 malignant
• USS or MMG guidance allows biopsy more than one
  suspicious lesion
• USS guided biopsy
• USS permits real time guidance of needle into
  lesion
• Simpler, quicker, cheaper and less invasive than
  stereotactic sampling
• Stereotactic MMG guided core biopsy
• Accurate computer guided method to biopsy
  impalpable MMG lesions
• Requires favourably sited lesion
• Less suitable for lesions close to chest wall or
  nipple/areola, or in small breasts
• Post biopsy MMG and specimen Xray to confirm
  adequacy of biopsy particularly when lesion is
  calcified
• Stereotactic core biopsy is costly, requires
  experienced radiologist and specialised equipment
  - only cost effective in centres associated with
  Breast Screen Units

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• Results of stereotactic or USS guided biopsy
• False neg 1-2 - May be higher as needle can
  reflect off lesion
• False pos rare
• DCIS up to 20 will contain invasive ca on open
  excision
• ADH warrants hook-wire biopsy

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• Advanced stereotactic techniques
• Mammotome
• 11G core biopsy under USS guidance
• Rotating coring instrument aided by suction
• Leave radioactive marker if completely excised
• Expensive 50 000 per instrument and 600 per
  needle
• Advanced breast biopsy instrument (ABBI)
• Pt prone with breast hanging through aperture in
  table
• Lesion sited with computerised stereotaxis and
  multiple machine driven cores sampled
• Also expensive but accurate

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Advantages of FNA and Core Biopsy over open biopsy

• Done under LA
• Enables single stage definitive surgery after
  confirming diagnosis reduce number of surgical
  procedures performed
• Allow diagnosis and hormone receptor analysis in
  pts with locally advanced inoperable breast
  cancer
• Core biopsy can affect decisions re axillary
  dissection core biopsy can distinguish invasive
  ca from CIS
• Compared with open biopsy, core biopsy is
  accurate without cost, morbidity and time off
  work associated with an open procedure
• Stereotactic core biopsy 1/5 cost of excision
  biopsy
• Number of operations minimised allowing surgical
  resources to be used mainly for therapeutic
  rather than diagnostic operations

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Open Biopsy

• Gold Standard
• Indications
• Cytological or histological diagnosis not
  obtained and still strong clinical suspicion
• Result of core biopsy is not consistent with
  radiological appearance
• Radial scar - should be localised and excised no
  matter what cytology or core results because of a
  real association with malignancy
• Independent procedure or part of planned
  treatment
• Lesions should ideally be excised completely
• Impalpable lesions require needle localisation
  under MMG or USS guidance
• Post excision, specimen oriented and sent for X
  ray if impalpable

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Screening

• Breast Screen Australia - introduced in 1991 to
  screen women aged 40 and over
• Women 50-69 are actively recruited
• Goal of breast screening is to identify
  asymptomatic / impalpable cancers to allow early
  intervention and improved outcomes
• Screening allows detection of small and LN
  negative tumours thereby significantly improving
  survival and allowing breast conserving treatment
• T1 tumours gt85 10 year survival
• Tumours lt10mm have lt10 ln pos rate
• 30 reduction in mortality from breast carcinoma
  in women 50-74 participating in breast screening
  with 2nd yearly MMG
• Much debate about the value of screening women
  40-49yrs

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References

• National Breast Cancer Centre. Clinical Practice
  Guidelines for the Management of Early Breast
  Cancer, 2nd Edition, Canberra, 2001.
• National Breast Cancer Centre. Breast FNA
  Cytology and Core Biopsy a Guide for Practice,
  1st Edition, Camberdown, 2004.
• Silverstein MJ. Recent Advances Diagnosis and
  treatment of early breast cancer. BMJ 1997
  314(7096)1736-1739.
• Furnival,C. Breast cancer Current Issues in
  Diagnosis and Treatment. ANZ J Surg.
  199767(1)47-58.
• Dennison G, Anand R, Makar H, Pain JA. A
  Prospective Study of the Use of Fine-Needle
  Aspiration Cytology and Core Biopsy in the
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• Legorreta AP, Chernicoff HO, Trinh JB, Parker RG.
  Diagnosis, clinical Staging and Treatment of
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• Drew PJ, Turnbull LW, Chattejee S, Read J,
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  breast for the evaluation of symptomatic breast
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• Kriege M, Brekelmans CTM, Boetes C, Besnard PE,
  Zonderland HM et al. Efficacy of MRI and
  Mammography for Breast-Cancer Screening in Women
  with a familial or Genetic predisposition.
  NEJM.2004351(5)427-37.

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References (2)

• Gottlieb,S.MRI does not reduce biopsies in
  diagnosing breast cancer. BMJ.2004329(7479)1362.
  
• Sauer T, Young K, Thoresen SO. Fine needle
  aspiration cytology in the work-up of
  mammographic and ultrasonographic findings in
  breast cancer screening an attempt at
  differentiating in situ and invasive carcinoma.
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  needle cytology and core biopsy in the diagnosis
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• Dahlstrom JE, Jain S, Sutton T, Sutton S.
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• Miller AB, To T, Baines CJ. The Canadian National
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