Pemeriksaan Karsinoma Mammae

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Strategi Deteksi Kanker PayudaraStadium AwalGani W Tambunan, Joko S Lukito, SoekiminLaboratorium Patologi AnatokikFakultas Kedokteran Universitas Sumatera Utara / Rumah Sakit Dr. Pirngadi, MedanABSTRAKSebagian besar kanker payudara ditemukan oleh penderita sendiri, yang berartipads kondisi stadium lanjut inoperabel. Oleh karena ukuran tumor umumnya berpengaruhterhadap prognosis, maka penanggulangan diprioritaskan pads upaya menemukantumor ini dalam ukuran kecil asimtomatik dengan cara : (1) pemeriksaan payudarasendiri (SARARI) dan (2) pemeriksaan payudara secara klinik (SARANIK) olehdokter, bidan ataupun paramedis yang terlatih. Apabila pada kedua pemeriksaan iniditemukan nodul, maka pemeriksaan dilanjutkan dengan (3) sitologi biopsi aspirasidengan/tanpa (4) mamografi ataupun (5) biopsi bedah. Prosedur, teknik dan peralatansitologi biopsi aspirasi sangat sederhana dan murah dengan ketepatan diagnosis yangtinggi. Kombinasi sitologi biopsi aspirasi dan mamografi memberikan ketetapan diagnosisalternatif, apabila biopsi aspirasi tidak dapat dilakukan atau gagal memberi informasiyang akurat.PENDAHULUANTumor payudara hampir selalu memberi kesan menakutkanbagi wanita. Bahkan banyak para pakar sependapat bahwa setiapnodul pads payudara dianggap sebagai kanker terutama padswanita golongan risiko tinggi walaupun kemungkinan tumorjinak tidak dapat diabaikan. Pendapat yang "berlebihan" inidapat dipahami, mengingat insiden kanker payudara tinggitidak hanya di negara sedang berkembang, tapi juga di negaramaju. Di Indonesia kanker payudara berada pada urutan ke duadari jenis kanker yang ada dan lebih kurang 60 - 80% ditemukanpads stadium lanjut yang berkaibat fatal').Tingkat pertumbuhan atau stadium kanker payudaraditentukaan tumor, penyebaran pads kelenjar getah bening didaerah ketiak ataupun supraklavikuler dan organ lain misalnyaparu, hati dan tulang. Semakin kecil tumor, kemungkinanpenyebaran tumor semakin kecil dan tindakan bedah kuratifdapat diharapkan walaupun sifatnya "sulit diramalkan" karenakemungkinan mikrometastasis tidak dapat diabaikan(2

. Olehsebab itu penanggulangan kanker payudara dewasa inidiprioritaskan path upaya menemukan kankerpada ukuran sekecilmungkin.Tujuan tulisan ini adalah untuk mengemukakan berbagaipendekatan sederhana untuk menemukan kanker payudarapads stadium awal secara efektif dan efieisn.ETIOLOGIPenyebab kanker payudara belum jelas diketahui, namunpengaruh hormonal merupakan faktor yang utama. Apabilapads wanita berusia kurang dari 35 tahun dilakukan kastrasiovarium ataupun adrenal, maka risiko kanker payudara padswanita tersebut lebih kecil dibanding dengan wanita biasa. Wanitayang menarkhe pads usia sebelum 11 tahun dan wanita yangsulit dapat anak, insiden kanker payudaranya lebih tinggidibanding wanita normal.10 Cermin Dunia Kedokteran, Edisi Khusus No. 80, 1992

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Faktor luar, antara lain kemungkinan makanan, diduga adakaitannya dengan insiden kanker payudara. Insiden kankerpayudara pada wanita Jepang lebih rendah dibanding wanitaBaratGolongan risikoGolongan risiko sering membantu dalam diagnosis karsinomapayudara. Yang dimaksud dengan golongan risiko adalahkelompok wanita yang mempunyai kemungkinan lebih tinggiterjangkit penyakit kanker payudara, dengan kriteria :1) Wanita berusia di atas 40 tahun2)Orang tua (ibu) menderita kanker payudara3) Saudara (kakak, adik) menderita kanker payudara4) Pernah menderita kanker pads salah satu payudara5) Penderita tumor jiank payudara6) Kehamilan pertama terjadi sesudah usia 35 tahun.PERTUMBUHANKanker payudara 95% merupakan karsinoma,'berasal dariepitel saluran dan kelenjar payudara. Pertumbuhan dimulai didalam duktus ataupun kelenjar lobulus yang disebut karsinomanoinvasif. Kemudian tumor menerobos ke luar dinding duktusatau kelenjar di daerah lobulus dan invasi ke dalam stroma, yangdikenal dengan nama karsinoma invasif. Pada pertumbuhanselanjutnya tumor meluas menuju fasia otot pektoralis ataupundaerah kulit yang menimbulkan perlengketan-perlengketan.Pada kondisi demikian, tumor dikategorikan stadium lanjutinoperabel.Penyebaran tumor terjadi melalui pembuluh getahbening, deposit dan tumbuh di kelenjar getah bening, sehinggakelenjar getah bening aksiler ataupun supraklavikuler mem-besar.Kemudian melalui pembuluh darah, tumor menyebarke organ jauh antara lain pare, hati, tulang dan otak. Akan tetapidari penelitian para pakar, mikrometastasis pads organ jauhdapat juga terjadi tanpa didahului penyebaran limfogen(2

).Beberapa penulis mengemukakan konsep bahwa karsinomapayudara merupakan penyakit sistemik; walaupun tumor kecil,namun kemungkinan mikrometastasis tidak dapat diabaikan.Namun demikian, stadium dan prognosis karsinoma payu-dara pada umumnya ditentukan berdasarkan ukuran tumor,luas invasi pada payudara, keterlibatan kelenjar getah beningaksiler ataupun supraklavikuler dan metastasis ke organ jauh.Semakin kecil ukuran tumor, tingkat pertumbuhan/stadiumsemakin rendah dan prognosis lebih baik.Faktor daya tangkal tubuhKarsinoma payudara sebagian meluas progresif, sebagiantumbuh laten bertahun-tahun dan bahkan ada pula yang meng-alami regresi (Townsend). Kejadian ini diduga ada kaitannyadengan faktor daya pertahanan tubuh yang disponsori jaringanlimfoid. Defek reaksi limfosit pads kelenjar getah bening diaksila mempercepat pertumbuhan tumor dan prognosis lebihburuk. Di samping itu ketergantungan tumor terhadap hormonterutama estrogen berpengaruh terhadap pertumbuhan tumor.GEJALA KLINIK

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Keluhan utama penderita adalah pembengkakan payudara.Perasaan sakit jarang terjadi, kalaupun ada Baru muncul padstingkat pertumbuhan yang lanjut. Oleh karena keluhan sakittidak ada, pasien tidak merasa perlu pergi berobat, sehinggatumor dibiarkan tumbuh tanpa menyadari bahaya yang akanterjadi. Itulah sebabnya sebagian besar (60-80%) penderitakanker payudara ditemukan pads tingkat pertumbuhan lanjutinoperabel.Pada situasi demikian sering ditemukan tumor melengketdengan kulit atau kelihatan seperti bisul atau borok disertaipembengkakan kelenjar getah bening di ketiak ataupun dileher. Pada keadan penyakit demikian, pengobatan biasanyahanya bersifat paliatif. Pengobatan kuratif dapat dilakukanapabila tumor ditemukan pads ukuran kecil atau stadium dini.METODE DETEKSI DINIWalaupun kemajuan pengobatan kanker dengan sitostatikasemakin meningkat, namun penemuan tumor pada stadium dinimerupakan faktor penting dalam penanggulangan kankerpayudara. Sebagian besar kanker payudara ditemukan olehpasien sendiri, artinya tumor dalam tingkat pertumbuhanlanjut. Untuk menemukan tumor ini pads stadium awal diper-lukan inisiatif pasien dan pemeriksaan medis :1)Pemeriksaan payudarasendiri (SARARI)Pemeriksaan payudara sendiri ternyata terbukti dapatmenemukan tumor pads ukuran kecil. Dengan pola pemeriksaantertentu payudara diperiksa sendiri setiap bulan 5-7 harisesudah haid berhenti. Pemeriksaan payudara sendiri waktusedang mandi sangat efektif karena dengan mempergunakansabun benjolan lebih mudah teraba. Apabila teraba benjolanwalaupun kecil dan tidak sakit, apalagi pads wanita golonganrisiko tinggi, segera diperiksakan pads dokter keluarga ataupundokter di Rumah Sakit/Puskesmas. Menurut penelitian paraahli, SARARI sangat bernilai dalam deteksi kanker payudarasedini mungkin(2

'4>.

2)Pemeriksaan payudara oleh secara klinis (SARANIS)Dokter umum merupakan ujung tombak dalampenaggulangan kesehatan masyarakat; diperkirakan mempunyaikesempatan luas untuk menemukan kanker payudara ukurankecil. Kesempatan ini mungkin, apabila pads setiap wanitayang berusia lebih dari 40 tahun atau wanita yang termasukgolongan risiko tinggi, walaupun dia datang karena penyakitlain, dilakukan pemeriksaan payudara secara klinis (SARANIS)oleh dokter, bidan atau paramedis wanita merupakan strategiuntuk menerobos kendala "budaya rasa malu kalau diperiksadokter pria yang sering terjadi di klin ik atau puskesmas. Beberapapenulis melaporkan bahwa spesialis kandungan tidak jarangmenemukan tumor payudara pads ukuran kecil.SARANIS dilakukan sistematis dengan langkah-langkahsebagai berikut :1)

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Pasien duduk berhadapan dengan petugas medis, diamatiCermin Dunia Kedokteran, Edisi Khusus No. 80, 19921 1

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simetrisasi atau perubahan bentuk kedua payudara.2)Kedua tangan pasien diangkat ke atas kepala sambilmemperhatikan simetrisasi ataupun perubahan gerakan keduapayudara. Adanya tarikan pada kulit merupakan pertandakern ungkinan keganasan.Untuk melihat lebihjelas, tarikan kulityang menutupmassa ditekan di antara dua jari tangan dan terjadidimpling sign.3)Palpasi kelenjar getah bening di daerah aksiler dilakukandengan tangan penderita diletakkan santai di alas tanganpemeriksa.4)Pada posisi fleksi kepala, daerah supraklavikuler dipalsasidengan cermat untuk melihat kemungkinan pembesarankelenjar getah bening.5)Pada posisi supine, kedua payudara dipalpasi sistematis mulaidaerah pinggir sampai ke daerah areola payudara. Palpasilebih intensif di daerah kuadran lateral atas, karena di daerahini lebih sering dijumpai karsinoma. Nodul lebih jelas terabaapabila di atas kulit payudara dilapukan sabun sambil dipalpasi.3)Pemeriksaan mamografiMamografi adalah foto payudara dengan mempergunakanalat khusus. Teknik sederhana, tidak sakit dan tidak adasuntikan kontras. Dengan cara ini kanker payudara ukuran kecil0.5 cm dapat diteksi; bahkan cara ini dapat dipergunakan sebagaialat skrining massal terutama golongan risiko tinggi walaupuntumomya tidak teraba.Apabila pads SARARI atau pemeriksaan SARADISditemukan benjolan pads payudara, pemeriksaan dilanjutkandengan mamografi. Pemeriksaan mamografi dilanjutkandengan pemeriksaan patologik : sitologi biopsi aspirasi ataupunbiopsi bedah. Ketepatan diagnosis mamografi lebih kurang 80%.Indikasi lain mamografi adalah para wanita golongan risikodengan keluhan bahwa dari puting susu keluar cairan coklat ataucampurdarah. Akhir-akhirini munculalatmutahirxeromamografiyang mempunyai kemampuan deteksi lebih akurat.USG sering dipergunakan untuk diagnosis kista padspayudara. Akan tetapi dengan adanya sitologi aspirasi pema-kaian USG makin berkurang.4)Biopsi aspirasiPemeriksaan sitologi biopsi aspirasi jarum sering diper-gunakan sebagai prosedur diagnosis berbagai tumor termasuktumor payudara dengan indikasio,61

:1)Diagnosis preoperatif tumor yang klinik diduga maligna.2)Diagnosis konfirmatif klinik tumor maligna ataupun tumor

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rekuren.3)Diagnosis tumor nopnneoplastik ataupun neoplastik.4)Mengambil bahan aspirat untuk kultur ataupun bahanpenelitian.Teknik dan peralatan sangat sederhana, murah dan cepatserta tidak ada komplikasi yang berarti. Dengan mempergunakanjarum halus dan semprit plastik 10 ml, bahan ekstrak jaringandiambil, dibuat sediaan hapus dan diwarnai dengan MGG.Dalam beberapa menit (15-30 menit) diagnosis preoperatifdapat ditentukan dan dalam waktu yang singkat tindakan lanjutdapat ditentukan. Akurasi diagnostik sitologi BAJAH 80-96%dan dengan kombinasi mamografi akurasi diagnostikmeningkat menjadi 98.7%0.7

).Sitologi positif merupakan manda untuk survai metastasisdan rencana pengobatan. Akan tetapi sitologi negatif, belumdapat dip

erg

unakan sebag

ai oettangan untuk menentukanterapi oleh karena kemungkinan negatif palsu dapat terjadi.Pada kasus demikian perlu diperhatikan aspek klinik. apabilaaspek klinik sesuai dengan sitologi negatif maka tindakanbedah dapat dilakukan. Sebaliknya pads kasus di mana sitologinegatif tidak sesuai dengan klinik hams dilakukan pemeriksaanbiopsi bedah. Aplikasi prosedur diagnosis sitologi aspirasipada tumor payudara, memungkinkan manajemen lebihsederhana.Kista merupakan salah satu indikasi sitologi biopsiaspirasi. Cairan kista jernih biasanya jinak dan apabila cairandievakuasi seluruhnya, kista tidak teraba (kolaps) dan seringtidak muncul kembali. Akan tetapi bila cairan kista coklat ataucampur darah dan cepat berulang, maka perlu dilakukanpemeriksaan lain seperti mamografi dan biopsi.5)True-cutJaringan diperoleh dengan mempergunakan jarum kaliberbesar yang dilengkapi alat pemotong jaringan. Pengambilanjaringan dilakukan di bawah anastesi lokal ataupun umum.Metode ini tidak banyak dipakai lagi oleh karena adanya sitologibiopsi aspirasi.6)Biopsi terbukaBiopsi terbuka (openbiopsy)adalah prosedur pengambilanjaringan dengan jalan operasi kecil, eksisi ataupun insisi yangdilakukan sebagai diagnosis preoperatif ataupun duranteoperationam. Di rumah sakit yang tidak mempunyai fasilitassitologi aspirasi atau mamografi, maka pads setiap benjolanpayudara terbuka dilakukan biopsi terbuka.Biopsi insisi durante operationam dan pemeriksaan

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histopatologi jaringan dengan teknik pemotongan beku (frozensection) dilakukan untuk mengetahui sifat tumor jinak atauganas. Dalam waktu yang singkat (5-10 menit) sifat tumordapat ditentukan dan tindakan bedah dapat dilakukan dalamsatu tahap.KEPUSTAKAAN1. Thomas JF, Fitharris BM, Redding WH dkk. Clinical examination,xeromammografi and fine needle aspiration cytology in diagnosis of breasttumours. BMJ. 1978; 2: 1139-1147.2. Tjindarbumi D. Penanganan kanker payudara dini dan lanjut. Naskahsimposium tumor ganas pada wanita. Bagian Patologi Fakultas KedokteranUI, Jakarta, 1987.3. Philip J, Harris G, Flaherti C, Joslin CAF. Clinical measure to assess thepractice and efficiency of breast self-examination. Cancer 1986; 58 : 973-7.4. Strax P. Strategy (motivation) for detection early breast cancer. Cancer 1980;46:926-9.1 2Cermin Dunia Kedokteran, Edisi Khusus No. 80, 1992

Mammography is the process of using low-dose amplitude-X-rays (usually around 0.7 mSv) to examine the human breast. The goal of mammography is the early detection of breast cancer, typically through detection of characteristic masses and/or microcalcifications. Mammography is believed to reduce mortality from breast cancer. No other imaging technique has been shown to reduce risk, but breast self-examination (BSE) and physician examination are considered essential parts of regular breast care.

In many countries routine mammography of older women is encouraged as a screening method to diagnose early breast cancer. The United States Preventive Services Task Force recommends screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older.[1]

Like all x-rays, mammograms use doses of ionizing radiation to create images. Radiologists then analyze the image for any abnormal findings. It is normal to use longer wavelength X-rays (typically Mo-K) than those used for radiography of bones.

At this time, mammography along with physical breast examination is the modality of choice for screening for early breast cancer. Ultrasound, ductography, and magnetic resonance imaging are adjuncts to mammography. Ultrasound is typically used for further evaluation of masses found on mammography or palpable masses not seen on mammograms. Ductograms are still used in some institutions for evaluation of bloody nipple discharge when the mammogram is non-diagnostic. MRI can be useful for further evaluation of questionable findings as well as for screening pre-surgical evaluation in

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patients with known breast cancer to detect any additional lesions that might change the surgical approach, for instance from breast-conserving lumpectomy to mastectomy. New procedures, not yet approved for use in the general public, including breast tomosynthesis may offer benefits in years to come.

Mammography has a false-negative (missed cancer) rate of at least 10 percent. This is partly due to dense tissues obscuring the cancer and the fact that the appearance of cancer on mammograms has a large overlap with the appearance of normal tissues.

Contents

[hide] 1 Procedure 2 "Work-up" process 3 Results 4 Risks

o 4.1 False positives o 4.2 False negatives

5 Other risks 6 Alternatives to mammography 7 Regulation 8 History 9 References

o 9.1 Footnotes o 9.2 Additional reading

10 External links

[edit] Procedure

During the procedure, the breast is compressed by a dedicated mammography machine to even out the tissue, to increase image quality, and to hold the breast still (preventing motion blur). Both front and side images of the breast are taken. Deodorant, talcum powder or lotion may show up on the X-ray as calcium spots, and women are discouraged from applying these on the day of their investigation.

Until some years ago, mammography was typically performed with screen-film cassettes. Now, mammography is undergoing transition to digital detectors, known as Full Field Digital Mammography (FFDM). This progress is some years later than in general radiology. This is due to several factors:

1. the higher resolution demands in mammography,2. significantly increased expense of the equipment,3. the fact that digital mammography has never been shown to be superior to film-

screen mammography for the diagnosis of breast cancer.

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Computed radiography (CR) may help speed the transition. CR allows facilities to continue to use their existing screen-film units but do the cassettes with an imaging plate that acts as a digital adapter.

As of March 1, 2007, 18.3% of facilities in the United States and its territories have at least one FFDM unit.[2] (The FDA includes computed radiography units in this figure.[3])

[edit] "Work-up" process

In the past several years, the "work-up" process has become quite formalized. It generally consists of screening mammography, diagnostic mammography, and biopsy when necessary, often performed via stereotactic core biopsy or ultrasound-guided core biopsy. After a screening mammogram, some women may have areas of concern which can't be resolved with only the information available from the screening mammogram. They would then be called back for a "diagnostic mammogram". This phrase essentially means a problem-solving mammogram. During this session, the radiologist will be monitoring each of the additional films as they are taken by a technologist. Depending on the nature of the finding, ultrasound may often used at this point, as well.

Generally the cause of the unusual appearance is found to be benign. If the cause cannot be determined to be benign with sufficient certainty, a biopsy will be recommended. The biopsy procedure will be used to obtain actual tissue from the site for the pathologist to examine microscopically to determine the precise cause of the abnormality. In the past, biopsies were most frequently done in surgery, under local or general anesthesia. The majority are now done with needles using either ultrasound or mammographic guidance to be sure that the area of concern is the area that is biopsied. These core biopsies require only local anesthesia, similar to what would be given during a small dental procedure.

One study shows that needle biopsies of liver malignancies rarely increase the likelihood that cancer will spread, and has not been found to occur with breast needle biopsies.[1]

Often women are quite distressed to be called back for a diagnostic mammogram. Most of these recalls will be false positive results. It helps to know these approximate statistics: of every 1,000 U.S. women who are screened, about 7% (70) will be called back for a diagnostic session (although some studies estimate the number closer to 10%-15%). About 10 of these will be referred for a biopsy; the remaining 60 are found to be of benign cause. Of the 10 referred for biopsy, about 3.5 will have a cancer and 6.5 will not. Of the 3.5 who do have cancer, about 2 have a low stage cancer that will be essentially cured after treatment. Mammogram results are often expressed in terms of the BI-RADS Assessment Category, often called a "BI-RADS score." The categories range from 0 (Incomplete) to 6 (Known biopsy – proven malignancy). In the UK mammograms are scored on a scale from 1-5 (1 = normal, 2 = benign, 3 = indeterminate, 4 = suspicious of malignancy, 5 = malignant).

While mammography is the only breast cancer screening method that has been shown to save lives, it is not perfect. Estimates of the numbers of cancers missed by mammography

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are usually around 10%–30%. This means that of the 350 per 100,000 women who have breast cancer, about 35-70 will not be seen by mammography. Reasons for not seeing the cancer include observer error, but more frequently it is because the cancer is hidden by other dense tissue in the breast and even after retrospective review of the mammogram, cannot be seen. Furthermore, one form of breast cancer, lobular cancer, has a growth pattern that produces shadows on the mammogram which are indistinguishable from normal breast tissue.

Computer-aided diagnosis (CAD) are being tested to decrease the number of cases of cancer that are missed in mammograms. In one test, a computer identified 71% of the cases of cancer that had been missed by physicians. However, the computer also flagged twice as many non-cancerous masses than the physicians did. In a second study of a larger set of mammograms, a computer recommended six biopsies that physicians did not. All six turned out to be cancers that would have been missed. (Destounis, et al., 2004) Generally, CAD systems in screening mammography have poor specificity and compare poorly to double reading (Taylor P, Champness J, Given-Wilson R, Johnston K, Potts H (2005). Impact of computer-aided detection prompts on the sensitivity and specificity of screening mammography. Health Technology Assessment, 9(6)).

While data are accumulating suggesting that CAD can find a few additional cancers, this should be put in perspective. The additional find rate was 20%, thus in a group of 10,000 women who will have about 40 cancers, CAD may help find an additional 8. The types of additional cancers that may be found are likely to be early and small.[citation needed] As of 2006, there have been no data to show that finding these additional cancers will have any effect on survival rate. Some feel that these cancers are likely to be found at the next screening, still at a curable stage, and therefore it remains to be proven whether CAD will be eventually found to have any effect on patient outcome.

A study released October 1, 2008, by British researchers revealed that using CAD in conjunction with a single reading by a physician may be as beneficial as a second reading by a physician. The study of 31,000 women, the largest of its kind to date, determined that the find rate for a single physician in conjunction with CAD as compared to two physicians was nearly identical[4]. Out of 227 cancers found, the CAD method found just one fewer than the 199 cancers found using two separate physicians.

[edit] Risks

[edit] False positives

The goal of any screening procedure is to examine a large population of patients and find the small number most likely to have a serious condition. These patients are then referred for further, usually more invasive, testing. Thus a screening exam is not intended to be definitive: It is intended to have a high sensitivity so as to not miss any cancers. The cost of this high sensitivity is a relatively large number of results that would be regarded as suspicious in patients without disease. This is true of mammography. The patients called back for further testing from a screening session (about 7%) are sometimes referred to as

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"false positives", implying an error. In fact, it is essential to call back many healthy patients for further testing to capture as many cases of cancer as possible.

Research shows[5] that false-positive mammograms may affect women's well-being and behavior. Some women who receive false-positive results may be more likely to return for routine screening or perform breast self-examinations more frequently. However, some women who receive false-positive results become anxious, worried and distressed about the possibility of having breast cancer, feelings that can last for many years.

[edit] False negatives

At the same time, mammograms also have a rate of missed tumors, or "false negatives." Accurate data regarding the number of false negatives are very difficult to obtain, simply because mastectomies cannot be performed on every woman who has had a mammogram to determine the false negative rate accurately. Estimates of the false negative rate depend on close follow-up of a large number of patients for many years. This is difficult in practice, because many women do not return for regular mammography making it impossible to know if they ever developed a cancer. Dr. Samuel S. Epstein, in his book, The Politics of Cancer, claims that in women ages 40 to 49, one in four instances of cancer is missed at each mammography. Researchers have found that breast tissue is denser among younger women, making it difficult to detect tumors. For this reason, false negatives are twice as likely to occur in premenopausal mammograms (Prate.) This is why the screening program in the UK does not start calling women for screening mammograms until the age of 50.

The importance of these missed cancers is not clear, particularly if the woman is getting yearly mammograms. Research on a closely related situation has shown that small cancers that are not acted upon immediately, but are observed over periods of even several years, will have good outcomes. A group of 3,184 women had mammograms which were formally classified as "probably benign." This classification is for patients who are not clearly normal but have some area of minor concern. This results, not in the patient being biopsied, but having early follow up mammography every six months for three years to guarantee no change. Of these 3,184 women, 17 (0.5%) did have cancers. Most importantly, when the diagnosis was finally made, they were all still stage 0 or 1, the earliest stages. Five years after treatment, none of these 17 women had evidence of recurrence. Thus, small early cancers, even though not acted on immediately, were still entirely curable (Sickles, AJR, 179:463-468, 1991).

Regardless of the precise number of false negatives, it is very clear that even if some tumors are missed, lives are saved when they are found. Women need to understand that a negative mammogram is not a perfect guarantee that there is no breast cancer present, but it is the best method we have available.

[edit] Other risks

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The radiation exposure associated with mammography is a potential risk of screening. The risk of exposure appears to be greater in younger women. The largest study of radiation risk from mammography concluded that for women 40 years of age or older, the risk of radiation-induced breast cancer was minuscule, particularly compared with the potential benefit of mammographic screening, with a benefit-to-risk ratio of 48.5 lives saved for each life lost due to radiation exposure.[6] Organizations such as the National Cancer Institute and United States Preventive Task Force take such risks into account when formulating screening guidelines.[7]

The majority of health experts agree that the risk of breast cancer for asymptomatic women under 35 is not high enough to warrant the risk of radiation exposure. For this reason, and because the radiation sensitivity of the breast in women under 35 is possibly greater than in older women, most radiologists will not perform screening mammography in women under 40. However, if there is a significant risk of cancer in a particular patient (BRCA positive, very positive family history, palpable mass), mammography may still be important. Often, the radiologist will try to avoid mammography, by using ultrasound, or MRI imaging.

Similarly, the risk of breast cancer to women over 55 very clearly justifies the risk of mammograms. The statistics about mammography and women between the ages of 40 and 55 are the most contentious. A 1992 Canadian National Breast Cancer Study showed that mammography had no positive effect on mortality for women between the ages of 40 and 50.[2] This study, however, is the only study to find this result. The study's critics pointed out that there were very serious design flaws in the study that invalidated these results.[who?]

While screening between 40 and 50 is still controversial, the preponderance of the evidence indicates that there is some small benefit in terms of early detection. Currently, the American Cancer Society, the National Cancer Institute, and the American College of Radiology encourage mammograms every two years for women ages 40 to 49.[8] In contrast, the American College of Physicians, a large internist group, has recently encouraged individualized screening plans as opposed to wholesale biennual screening of women aged 40 to 49.[9]

[edit] Alternatives to mammography

While the cost of mammography is relatively low, its sensitivity is not ideal, with reports listing the range from 45% to about 90% depending on factors such as the density of the breast. Neither is the X-ray based technology completely benign, as noted above. Therefore there is considerable ongoing research into the use of alternative technologies.

One approach, contrast enhanced magnetic resonance imaging (MRI), has shown substantial progress. In this method, the breast is scanned in an MRI device before and after the intravascular injection of a contrast agent (Gadolinium DTPA). The pre-contrast images are "subtracted" from the post-contrast images, and any areas that have increased blood flow are seen as bright spots on a dark background. Since breast cancers generally

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have an increased blood supply, the contrast agent causes these lesions to "light up" on the images. The available literature suggests that the sensitivity of contrast-enhanced breast MRI is considerably higher than that of either radiographic mammography or ultrasound and is generally reported to be in excess of 95% (though not all reported studies have been as encouraging). The specificity (the confidence that a lesion is cancerous and not a false positive) is only fair, thus a positive finding by MRI should not be interpreted as a definitive diagnosis. The reports of 4,271 breast MRIs from eight large scale clinical trials were reviewed recently by CD Lehman. Overall the sensitivity ranged from 71% to 100% in these reports, however the call-back rates were low at 10% and the risk of having a benign biopsy was reported at 5%, a significant improvement over mammography.

Several medical instrument vendors have entered this arena with breast MRI solutions. One company, Aurora Systems, stands out as being the only manufacturer to make a breast-dedicated unit and as the exclusive patent holder of certain solutions to fat signal suppression that appear to be more or less essential. Siemens, General Electric and Philips Medical, the leading manufacturers of MRI instruments, offer breast MRI products or add-ons, and several third-party companies (e.g., MRI Devices/IGC) offer aftermarket products to enable breast MRI on conventional MRI instruments.

[edit] Regulation

Mammography facilities in the United States and its territories (including military bases) are subject to the Mammography Quality Standards Act (MQSA). The act requires annual inspections and accredition every 3 years through an FDA-approved body. Facilities found deficient during the inspection or accreditation process can be barred from performing mammograms until corrective action has been verified or, in extreme cases, can be required to notify past patients that their exams were sub-standard and should not be trusted.

At this time MQSA applies only to traditional mammography and not related scans such as breast ultrasound, stereotactic breast biospy, or breast MRI.

[edit] History

Screening mammograms were first shown to save lives in research published by Sam Shapiro, Philip Strax and Louis Venet in 1967.

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S. Oertel YC. Fine needle aspiration of breast. Butterworth 1987.8. Tambunan GW. Karsinoma payudara. Dalam : Diagnosis dan Tatalaksana6. Drell SR, Sterret GF, Walters MNI, Whitaker D. Manual and Atlas of FineSepuluh Jenis Kanker Terbanyak di Indonesia, Handoyo (ed), Jakarta;Needle Aspiration Cytology. Churchill Livingstone 1986. p. 87-113.Penerbit Buku Kedokteran EGC, 1991.r

7. Tambunan GW. Penuntun biopsi aspirasi jarum halus. Aspek klinik dan9. Townsend CM. Management of breast cancer. Surgery and ajuvant therapy.sitologi neoplasma. Jakarta; Penerbit Hipokrates, 1990.Clinical Symposia 1987; 39 : 1-32 Ciba-Geigy.Cermin Dunia Kedokteran, Edisi Khusus No. 80, 19921 3

Breast Biopsy

Several methods for breast biopsy now exist. The most appropriate method of biopsy for a patient depends upon a variety of factors, including the size, location, appearance and characteristics of the abnormality.

[edit] Fine Needle Aspiration

(FNA) Fine needle aspiration (FNA) is a percutaneous ("through the skin") procedure that uses a fine needle and a syringe to sample fluid from a breast cyst or remove clusters of cells from a solid mass. With FNA, the cellular material taken from the breast is usually sent to the pathology laboratory for analysis. A technique similar to FNA can also be used by the radiologist or surgeon to drain fluid from a benign cyst. This procedure is called cyst aspiration. A Fine Needle Aspiration procedure is generally almost painless and takes only a few minutes to perform.

[edit] Core Needle Biopsy

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A core needle biopsy is a procedure that removes small but solid samples of tissue using a hollow "core" needle. For palpable (“able to be felt”) lesions, the physician is fixing the lesion with one hand and performing a freehand needle biopsy with the other. In case of non-palpable lesions stereotactic mammography or ultrasound guidance is used. With stereotactic mammography it is possible to pinpoint the exact location of a mass based on images taken from two different angles of the x-ray machine. With ultrasound, the radiologist or surgeon can watch the needle on the ultrasound monitor to help guide it to the area of concern. The needle used during core needle biopsy is larger than the needle used with FNA. The core biopsy needle also has a special cutting edge allowing removal of a bigger sample of tissue. With Core Needle Biopsy a relatively large sample can be removed through a small single incision in the skin. Typically, the breast area is first locally anesthetized with a small amount of anesthetic fluid. Then, the needle is placed into the breast. As with FNA, the radiologist or surgeon will guide the needle into the area of concern by palpating the lump. If the lesion can’t be felt the core needle biopsy is performed under image-guidance using either stereotactic mammography, ultrasound or even magnetic resonance imaging (MRI). A core needle biopsy procedure takes a few minutes to perform and is almost painless.

[edit] Vacuum Assisted Biopsy

Vacuum Assisted Biopsy is a version of Core Needle Biopsy using a vacuum technique to assist the collection of the tissue sample. The needle normally has a lateral (“from the side”) opening and can be rotated allowing multiple samples to be collected through a single skin incision. The Vacuum Assisted Biopsy procedure is similar to normal Core Needle Biopsy.

[edit] Open Surgical Biopsy

Open Surgical Biopsy means that a large mass or lump is removed during a surgical procedure. Surgical biopsy requires an approximately 3 to 5 centimeters incision and is normally performed in an operating room in sterile conditions. Open surgical biopsy in some cases can be performed with local anesthesia but in most cases general anesthesia may be necessary. Ten years ago, most breast biopsies were open surgical procedures. Today most patients are candidates for less invasive biopsy procedures such as core needle biopsy. Depending on the location of the lesion to be biopsied, a radiologist will often perform needle localization beforehand to guide the surgeon to the site being biopsied.

[edit] Skin Biopsy

Multiple methods for skin biopsy exist. Each has its own limitation and problems. Most are done under local anesthesia in a doctor's office. The result is very dependent on the clinical history presented to the pathologist, and also the method utilized. A shave biopsy

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is absolutely useless in diagnosising vasculitis, whereas an excisional biopsy might be excessive in diagnosing a possible basal cell carcinoma.

[edit] Shave biopsy

This is done with either a small scalpel blade, a curved razor blade, or a broken piece of "safety" razor. The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while other have great difficulty securing the devices. Ideally, the razor will shave only a small fragment of protruding tumor and leaving the skin relatively flat after the procedure. Hemostasis is obtained using light electrocautery, Monsel solution, or aluminum chloride. This is the ideal method of diagnosis for basal cell cancer. It can be used to diagnose squamous cell carcinoma and melanoma-in-situ, however, the doctor's understanding of the growth of these last two cancers should be considered before one uses the shave method. The punch or incisional method is better for the latter two cancers as false negative is less likely to occur (i.e. calling a squamous cell cancer an actinic keratosis or keratinous debris). Hemostasis for the shave technique can be difficult if one relied on electrocautery alone. A small "shave" biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone. Pressure dressing or chemical astringent can help in hemostasis in patients taking anticoagulants.

[edit] Punch biopsy

This is done with a round shaped knife ranging in size from 1mm to 8 mm. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method. Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. Disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases. The common punch size use to diagnose most inflammatory skin condition is the 3.5 or 4 mm punch. Ideally, the punch biopsy include the full thickness skin and subcutanous fat in the diagnosis of skin diseases. The punch biopsy is preferred over the shave biopsy for the diagnosis of squamous cell carcinoma and for melanomas. One or two sutures are required to close most punch biopsies with the exception of the smallest punches. Two "dog ear" defects can result in punch biopsies much larger than 5 mm, thus an incisional biopsy is preferred on larger lesions.

[edit] Incisional biopsy

When a cut is made through the entire dermis down to the subcutanous fat. A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel. Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin). Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutanous tissue can

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be obtained than a punch biopsy. Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound. Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization. Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width.

[edit] Excisional biopsy

This is essentially the same as incisional biopsy, except the entire lesion or tumor is included. This is the ideal method of diagnosis of small melanomas (when performed as an excision). Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically. This "excisional" biopsy is often done with a narrow margin to make sure the deepest thickness of the melanoma is given before prognosis is decided. However, as many melanoma-in-situs are large and on the face, a physician often chose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy. An initial small punch biopsy of a melanoma might say "severe cellular atypia, recommend wider excision". At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a "false positive" clinical diagnosis.

[edit] Curettage biopsy

This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted. The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells.

[edit] Fine needle aspirate

This is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe. It is a method used to diagnose tumor deep in the skin or lymphnodes under the skin. The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis. A fine needle aspirate can be done with simply a large bore needle and a small syringe (1 cc) that can generate rapid changes in suction pressure. Fine needle aspirate can be used to distinguish a cystic lesion from a lipoma. Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide. Many center have dedicated team used in the harvest of fine needle aspirate.

[edit] "Scoop", "scallop", or "shave" excision

A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion. An author published the result of this method and advocated it as better than standard excision and less time consuming. The added

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economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy. This save the added time for hemostasis, instruments, and suture cost. The great disadvantage, seen years later is the numerous scallop scars, and a very difficult to deal with lesions called a "recurrent melanocytic nevus". What has happened is that many "shave" excisions does not adequately penetrate the dermis or subcutanous fat enough to include the entire melanocytic lesion. Residual melanocytes regrow into the scar. The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevus gives the perfect dermatoscopic picture of a melanoma. When a second physicians re-examine the patient, he or she has no choice but to recommend the reexcision of the scar. If one does not have access to the original pathology report, it is impossible to tell a recurring nevus from a severely dysplastic nevus or a melanoma. As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of the scar showing residual pigmentation. The second issue with the shave excision is fat herniation, iatrogenic anetoderma, and hypertrophic scarring. As the deep shave excision either completely remove the full thickness of the dermis or greatly diminishing the dermal thickness, subcutanous fat can herniate outward or pucker the skin out in an unattractive way. In areas prone to friction, this can result in pain, itching, or hypertrophic scarring.

[edit] History

One of the earliest diagnostic biopsies was developed by the Arab physician Abulcasim (1013-1107 AD). A needle was used to puncture a goiter, and the material issuing was characterized. [1]

[edit] Cancer

When cancer is suspected, a variety of biopsy techniques can be applied. An excisional biopsy is an attempt to remove the entire lesion. When the specimen is evaluated, in addition to diagnosis, the amount of uninvolved tissue around the lesion, the surgical margin of the specimen is examined to see if the disease has spread beyond the area biopsied. "Clear margins" or "negative margins" means that no disease was found at the edges of the biopsy specimen. "Positive margins" means that disease was found, and a wider excision may be needed, depending on the diagnosis. When intact removal is not indicated for a variety of reasons, a wedge of tissue may be taken in an incisional biopsy. In some cases, a sample can be collected by devices that "bite" a sample. A variety of sizes of needle can collect tissue in the lumen (‘’core biopsy’’). Smaller diameter needles collect cells and cell clusters, fine needle aspiration biopsy. [2] Pathologic examination of a biopsy can determine whether a lesion is benign or malignant, and can help differentiate between different types of cancer. In contrast to a biopsy that merely samples a lesion, a larger excisional specimen called a resection may come to a pathologist, typically from a

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surgeon attempting to eradicate a known lesion from a patient. For example, a pathologist would examine a mastectomy specimen, even if a previous nonexcisional breast biopsy had already established the diagnosis of breast cancer. Examination of the full mastectomy specimen would confirm the exact nature of the cancer (subclassification of tumor and histologic "grading") and reveal the extent of its spread (pathologic "staging").

[edit] Precancerous conditions

For easily detected and accessed sites, any suspicious lesions may be assessed. Originally, this was skin or superficial masses. X-ray, then later CT, MRI, and ultrasound along with endoscopy extended the range.

[edit] Inflammatory conditions

A biopsy of the temporal arteries is often performed for suspected vasculitis. In inflammatory bowel disease (Crohn's disease and ulcerative colitis), frequent biopsies are taken to assess the activity of disease and to assess changes that precede malignancy. [3]

Biopsy specimens are often taken from part of a lesion when the cause of a disease is uncertain or its extent or exact character is in doubt. Vasculitis, for instance, is usually diagnosed on biopsy.

MammografiDari Wikipedia bahasa Indonesia, ensiklopedia bebas

(Dialihkan dari Mamografi)Langsung ke: navigasi, cari

Mammografi adalah proses pemeriksaan payudara manusia menggunakan sinar-X dosis rendah (umumnya berkisar 0,7 mSv). Mammografi digunakan untuk melihat beberapa tipe tumor dan kista, dan telah terbukti dapat mengurangi mortalitas akibat kanker payudara. Selain mammografi, pemeriksaan payudara sendiri dan pemeriksaan oleh dokter secara teratur merupakan cara yang efektif untuk menjaga kesehatan payudara. Beberapa negara telah menyarankan mammografi rutin (1-5 tahun sekali) bagi perempuan yang telah melewati paruh baya sebagai metode screening untuk mendiagnosa kanker payudara sedini mungkin.

[sunting] Penerapan mammografi

Sebagaimana penggunaan sinar-X lainnya, mammogram menggunakan radiasi ion untuk menghasilkan gambar. Radiolog kemudian menganalisa gambar untuk menemukan adanya pertumbuhan yang abnormal. Walaupun teknologi mammografi telah banyak mengalami kemajuan dan inovasi, ada komunitas medis yang meragukan penggunaan

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mammografi karena tingkat kesalahan yang masih tinggi dan karena radiasi yang digunakan dapat menimbulkan bahaya.

Diketahui bahwa sekitar 10% kasus kanker tidak terdeteksi dengan mammografi (missed cancer). Hal itu disebabkan antara lain oleh jaringan normal yang lebih tebal disekitar kanker, atau menutupi jaringan kanker sehingga jaringan kanker tidak terlihat.

Pada saat ini, mammografi masih menjadi standar terbaik untuk screening dini kanker payudara. Ultrasound, Ductography, dan Magnetic Resonance merupakan beberapa teknik lain yang juga digunakan untuk memperkuat hasil mammografi. Ductogram digunakan untuk mengevaluasi darah yang keluar dari puting. Magnetic resonance imaging (MRI) digunakan untuk evaluasi lanjutan atau sebelum operasi untuk melihat adanya daerah abnormal lainnya.

Detailed Guide: Breast Cancer

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How Is Breast Cancer Diagnosed?

While breast cancer is sometimes found after symptoms appear, many women with early breast cancer have no symptoms of the disease. This is why getting the recommended screening tests (as described in "Can breast cancer be found early?") before any symptoms develop is so important.

If something suspicious is found during a screening exam, or if you have any of the symptoms of breast cancer described below, your doctor will use one or more methods to find out if the disease is present. If cancer is found, other tests will be done to determine the stage (extent) of the cancer.

Signs and symptoms

Although widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms, some breast cancers are not found by mammogram, either because the test was not done or because, even under ideal conditions, mammograms do not find every breast cancer.

The most common sign of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded. For this reason, it is important that any new breast mass or lump be checked by a health care professional experienced in diagnosing breast diseases.

Other possible signs of breast cancer include:

swelling of all or part of a breast (even if no distinct lump is felt) skin irritation or dimpling breast or nipple pain nipple retraction (turning inward) redness, scaliness, or thickening of the nipple or breast skin a discharge other than breast milk

Sometimes a breast cancer can spread to underarm lymph nodes and cause a lump or swelling there, even before the original tumor in the breast tissue is large enough to be felt.

Medical history and physical exam

If you have any signs or symptoms that might be due to breast cancer, be sure to see your doctor as soon as possible. Your doctor will ask you questions about your symptoms, any other health problems, and possible risk factors for benign breast conditions or breast cancer.

Your breasts will be thoroughly examined for any lumps or suspicious areas and to feel

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their texture, size, and relationship to the skin and chest muscles. Any changes in the nipples or the skin of your breasts will be noted. The lymph nodes in the armpit and above the collarbones may be palpated (felt), because enlargement or firmness of these lymph nodes might indicate spread of breast cancer. Your doctor may also do a complete physical exam to judge your general health and whether there is any evidence of cancer that may have spread.

If breast symptoms and/or the results of your physical exam suggest breast cancer might be present, more involved tests will likely be done. These might include imaging tests, looking at samples of nipple discharge, or doing biopsies of suspected areas.

Imaging tests used to evaluate breast disease

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including to help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment has been effective.

Diagnostic mammograms

Although mammograms are mostly used for screening, they can also be used to examine the breast of a woman who has a breast problem. This can be a breast mass, nipple discharge, or an abnormality that was found on a screening mammogram. In some cases, special images known as cone views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.

A diagnostic mammogram can show:

That the abnormality is not worrisome at all. In these cases the woman can usually return to having routine yearly mammograms.

That a lesion (area of abnormal tissue) has a high likelihood of being benign (not cancer). In these cases, it is common to ask the woman to come back sooner than usual for her next mammogram, usually in 4 to 6 months

That the lesion is more suspicious, and a biopsy is needed to tell if it is cancer.

Even if the mammograms show no tumor, if you or your doctor can feel a lump, then usually a biopsy will be needed to make sure it isn't cancer. One exception would be if an ultrasound exam finds that the lump is a simple cyst (a fluid-filled sac), which is very unlikely to be cancerous.

Digital mammograms: A digital mammogram (also known as a full-field digital mammogram, or FFDM) is like a standard mammogram in that x-rays are used to produce an image of your breast. The differences are in the way the image is recorded,

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viewed by the doctor, and stored. Standard mammograms are recorded on large sheets of photographic film. Digital mammograms are recorded and stored on a computer. After the exam, the doctor can look at them on a computer screen and adjust the image size, brightness, or contrast to see certain areas more clearly. Digital images can also be sent electronically to another site for a remote consult with breast specialists. While many centers do not offer the digital option at this time, it is expected to become more widely available in the future.

Because digital mammograms cost more than standard mammograms, studies are now under way to determine which form of mammogram will benefit more women in the long run. Some studies have found that women who have a FFDM have to return less often for additional imaging tests because of inconclusive areas on the original mammogram. A recent large study found that a FFDM was more accurate in finding cancers in women younger than 50 and in women with dense breast tissue, although the rates of inconclusive results were similar between FFDM and film mammograms. It is important to remember that a standard film mammogram also is effective for these groups of women, and that they should not miss their regular mammogram if a digital mammogram is not available.

Computer-aided detection and diagnosis (CAD): Over the past 2 decades, computer-aided detection and diagnosis (CAD) has been developed to help radiologists detect suspicious changes on mammograms. This can be done with standard film mammograms or with digital mammograms.

Computers can help doctors identify abnormal areas on a mammogram by acting as a second set of "eyes." For standard mammograms, the film is fed into a machine which converts the image into a digital signal that is then analyzed by the computer. Alternatively, the technology can be applied to a digital mammogram. The computer then displays the image on a video screen, with markers pointing to areas that the radiologist should check especially closely.

It's not yet clear how useful CAD is. Some doctors find it helpful, but a recent large study found it did not significantly improve the accuracy of breast cancer detection. It did, however, increase the number of women who needed to have breast biopsies. Further research of this approach is needed.

Magnetic resonance imaging (MRI) of the breast

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material called gadolinium is often injected into a vein before or during the scan to show details better.

MRI scans can take a long time -- often up to an hour. You have to lie inside a narrow

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tube, which is confining and may upset people with claustrophobia (a fear of enclosed spaces). The machine also makes loud buzzing and clicking noises that you may find disturbing. Some places provide headphones with music to block this out. MRIs are also expensive, although insurance plans generally pay for them in some situations, such as once cancer is diagnosed.

Although MRI machines are quite common, they need to be specially adapted to look at the breast. It's important that MRI scans of the breast be done on one of these specially adapted machines.

MRI can be used along with mammograms for screening women who have a high risk of developing breast cancer, or it can be used to better examine suspicious areas found by a mammogram. MRI is also used for women who have been diagnosed with breast cancer to better determine the actual size of the cancer and to look for any other cancers in the breast.

Breast ultrasound

Ultrasound, also known as sonography, uses sound waves to outline a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is often first lubricated with ultrasound gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image that is displayed on a computer screen. This test is painless and does not expose you to radiation.

Ultrasound has become a valuable tool to use along with mammography because it is widely available and less expensive than other options, such as MRI. The use of ultrasound instead of mammograms for breast cancer screening is not recommended. Usually, breast ultrasound is used to target a specific area of concern found on the mammogram. Ultrasound helps distinguish between cysts (fluid-filled sacs) and solid masses and between benign and cancerous tumors.

Ultrasound may be most helpful in women with very dense breasts. Clinical trials are now looking at the benefits and risks of adding breast ultrasound to screening mammograms in women with dense breasts and a higher risk of breast cancer.

Ductogram

This test, also called a galactogram, is sometimes helpful in determining the cause of nipple discharge. In this test a very thin plastic tube is placed into the opening of the duct in the nipple. A small amount of contrast medium is injected, which outlines the shape of the duct on an x-ray image and shows if there is a mass inside the duct.

Newer imaging tests

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Newer tests such as scintimammography and tomosynthesis are not used commonly and are still being studied to determine their usefulness. They are described in the section, "What's New in Breast Cancer Research and Treatment?"

Other tests

Nipple discharge exam

If you are having nipple discharge, some of the fluid may be collected and looked at under a microscope to see if any cancer cells are in it. Most nipple discharges or secretions are not cancer. In general, if the secretion appears milky or clear green in color, cancer is very unlikely. If the discharge is red or red-brown, suggesting that it contains blood, it might possibly be caused by cancer, although an injury, infection, or benign tumors are more likely causes.

Even when no cancer cells are found in a nipple discharge, it is not possible to say for certain that a breast cancer is not there. If a patient has a suspicious mass, a biopsy of the mass is necessary, even if the nipple discharge does not contain cancer cells.

Ductal Lavage and Nipple Aspiration

Ductal lavage is an experimental test developed for women who have no symptoms of breast cancer but are at very high risk for the disease. It is not a test to screen for or diagnose breast cancer, but it may help give a more accurate picture of a woman's risk of developing it.

Ductal lavage can be done in a doctor's office or an outpatient facility. An anesthetic cream is applied to numb the nipple area. Gentle suction is then used to help draw tiny amounts of fluid from the milk ducts up to the nipple surface, which helps locate the ducts' natural openings. A tiny tube (called a catheter) is then inserted into a duct opening. Saline (salt water) is slowly infused into the catheter to gently rinse the duct and collect cells. The ductal fluid is withdrawn through the catheter and sent to a lab, where the cells are viewed under a microscope.

Ductal lavage is not considered appropriate for women who aren't at high risk for breast cancer. It is not clear if it will ever be a useful tool. The test has not been shown to detect cancer early. It is more likely to be useful as a test of cancer risk rather than as a screening test for cancer. More studies are needed to better define the usefulness of this test.

Nipple aspiration also looks for abnormal cells arising in the ducts, but is much simpler, because nothing is inserted into the breast. The device for nipple aspiration uses small cups that are placed on the woman's breasts. The device warms the breasts, gently compresses them, and applies light suction to bring nipple fluid to the surface of the breast. The nipple fluid is then collected and sent to a lab for analysis. As with ductal

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lavage, the procedure may be useful as a test of cancer risk but is not appropriate as a screening test for cancer. The test has not been shown to detect cancer early.

Biopsy

During a biopsy, the doctor removes a sample of the suspicious area to be looked at under a microscope. A biopsy is done when mammograms, other imaging tests, or the physical exam finds a breast change (or abnormality) that is possibly cancer. A biopsy is the only way to tell if cancer is really present.

There are several types of biopsies, such as fine needle aspiration biopsy, core (large needle) biopsy, and surgical biopsy. Each has its pros and cons. The choice of which to use depends on your specific situation. Some of the factors your doctor will consider include how suspicious the lesion appears, how large it is, where in the breast it is located, how many lesions are present, other medical problems you may have, and your personal preferences. You might want to discuss the pros and cons of different biopsy types with your doctor.

Fine needle aspiration biopsy

In an fine needle aspiration (FNA) biopsy , the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area, which is then looked at under a microscope. The needle used for FNA biopsy is thinner than the ones used for blood tests.

If the area to be biopsied can be felt, the needle can be guided into the area of the breast change while the doctor is feeling (palpating) it.

If the lump can't be felt easily, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass. Or the doctor may use a method called stereotactic needle biopsy to guide the needle. For stereotactic needle biopsy, computers map the exact location of the mass using mammograms taken from 2 angles, which helps the doctor guide the needle to the right spot.

A local anesthetic (numbing medicine) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic may actually be more uncomfortable than the biopsy itself.

Once the needle is in place, fluid is drawn out. If the fluid is clear, the lump is probably a benign cyst. Bloody or cloudy fluid can mean either a benign cyst or, very rarely, a cancer. If the lump is solid, small tissue fragments are drawn out. A pathologist will look at the biopsy tissue or fluid under a microscope to determine if it is cancerous.

While an FNA biopsy is the easiest type of biopsy to have, it has some disadvantages. It can sometimes miss a cancer if the needle is not placed among the cancer cells. And even

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if cancer cells are found, it is usually not possible to determine if the cancer is invasive. In some cases there may not be enough cells to perform some of the other lab tests that are routinely done on breast cancer specimens. If the FNA biopsy does not provide a clear diagnosis, or your doctor is still suspicious, a second biopsy or a different type of biopsy should be done.

Core needle biopsy

A core biopsy uses a larger needle to sample breast changes felt by the doctor or pinpointed by ultrasound or mammogram. (When mammograms taken from different angles are used to pinpoint the biopsy site, this is known as a stereotactic core needle biopsy.) In some centers, the biopsy can be guided by an MRI scan.

The needle used in core biopsies is larger than that used in FNAB. It removes a small cylinder of tissue (about 1/16- to 1/8-inch in diameter and ½-inch long) from a breast abnormality. Depending on whether the abnormal area can be felt, about 3 to 5 cores are usually removed. The biopsy is done using local anesthesia (where you are awake but the area is numbed) in an outpatient setting.

Because it removes larger pieces of tissue, a core needle biopsy is more likely than an FNAB to provide a clear diagnosis, although it may still miss some cancers.

Larger core biopsies: Two newer stereotactic biopsy methods can remove more tissue than a core biopsy:

The Mammotome® is a type of vacuum-assisted biopsy. For this procedure the skin is numbed and a small incision (about ¼ inch) is made. A hollow probe is inserted through the incision into the abnormal area of breast tissue. A cylinder of tissue is then suctioned in through a hole in the side the probe, and a rotating knife within the probe cuts the tissue sample from the rest of the breast. The Mammotome procedure is done as an outpatient. No stitches are needed, and there is minimal scarring. This method usually removes about twice as much tissue as core biopsies.

The ABBI method (short for Advanced Breast Biopsy Instrument) uses a probe with a rotating circular knife and thin heated electrical wire to remove a large cylinder of abnormal tissue. While in some cases it may be able to remove an entire mass, it also removes more normal breast tissue than other core biopsy techniques. It usually requires a few stitches afterward, and is more likely to leave a small scar.

Surgical (open) biopsy

Sometimes, surgery is needed to remove all or part of the lump for microscopic examination. This is referred to as a surgical biopsy or an open biopsy. Usually this is an

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excisional biopsy, where the surgeon removes the entire mass or abnormal area, as well as a surrounding margin of normal-appearing breast tissue (as opposed to an incisional biopsy, where only part of the mass is removed). In rare cases, this type of biopsy can be done in the doctor's office, but it is more commonly done in the hospital's outpatient department under a local anesthesia (where you are awake, but your breast is numbed). You may also be given medicine to make you drowsy.

During a surgical breast biopsy the surgeon may use a procedure called stereotactic wire localization if there is a small lump that is hard to locate by touch or if an area looks suspicious on the x-ray but cannot be felt. After the area is numbed with local anesthetic, a thin hollow needle is placed into the breast, and x-ray views are used to guide the needle to the suspicious area. Once the tip of the needle is in the right spot, a thin wire is inserted through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed. The surgeon can then use the wire as a guide to the abnormal area to be removed. The surgical specimen is sent to the lab to be looked at under a microscope (see below).

This type of biopsy is more involved than an FNA biopsy or a core needle biopsy, although it is more likely to result in an accurate diagnosis and, in some cases, may be the only surgery that is needed. It typically requires several stitches and may leave a scar.

Lymph node dissection and sentinel lymph node biopsy

These procedures are done specifically to look for cancer in the lymph nodes. They are described in more detail in the section, "How is breast cancer treated?"

Laboratory examination of breast cancer tissue

Once samples of breast tissue have been obtained from a biopsy, they are looked at in the lab to determine whether breast cancer is present and if so, what type it is. Other lab tests can help determine how quickly a cancer is likely to grow and (to some extent) what treatments are likely to be effective.

If a benign condition is diagnosed, no further treatment is needed. Still, it is important to find out from with your doctor if the benign condition places you at higher risk for breast cancer in the future and what type of follow-up you may need.

If the diagnosis is cancer, there should be time for you to learn about the disease and to discuss treatment options with your cancer care team, friends, and family. It is usually not necessary to rush into treatment. You may want to get a second opinion before deciding on what treatment is best for you.

Type of breast cancer

The tissue removed during the biopsy (or during surgery) is first looked at under a

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microscope to see if cancer is present and whether it is in situ (not invasive) or invasive. The biopsy is also used to determine the cancer's type. The different types of breast cancer are defined in the section, "What is breast cancer?"

The most common types, invasive ductal and invasive lobular cancer, generally are treated in the same way. In some cases, breast cancer types that tend to have a more favorable or unfavorable prognosis may be treated differently.

Breast cancer grade

A pathologist also assigns a grade to the cancer, which is based on how closely the biopsy sample resembles normal breast tissue. The grade helps predict a woman's prognosis. In general, a lower grade number indicates a slower-growing cancer that is less likely to spread, while a higher number indicates a faster-growing cancer that is more likely to spread.

Histologic tumor grade (sometimes called the Bloom-Richardson grade, Scarff-Bloom-Richardson grade, or Elston-Ellis grade) is based on the arrangement of the cells in relation to each other: whether they form tubules; how closely they resemble normal breast cells (nuclear grade); and how many of the cancer cells are in the process of dividing (mitotic count). This system of grading is used for invasive cancers but not for in situ cancers.

Grade 1 (well differentiated) cancers have relatively normal-looking cells that do not appear to be growing rapidly and are arranged in small tubules.

Grade 2 (moderately differentiated) cancers have features between grades 1 and 3.

Grade 3 (poorly differentiated) cancers, the highest grade, lack normal features and tend to grow and spread more aggressively.

The tumor grade is most important in patients who have small tumors and no lymph node involvement. Patients with small, well-differentiated tumors may require no further treatment after the tumor is removed, while patients with moderately or poorly differentiated tumors usually receive additional hormonal or chemotherapy.

Ductal carcinoma in situ (DCIS) is sometimes given a nuclear grade, which describes how abnormal the cancer cells appear. The presence or absence of necrosis (areas of dead or degenerating cancer cells), which might indicate a more aggressive cancer, is also noted. Other factors important in determining the prognosis for DCIS include the surgical margin (how close the cancer is to the edge of the specimen) and the size (amount of breast tissue affected by DCIS). In situ cancers with high nuclear grade, necrosis, cancer at or near the edge of the sample, or large areas of DCIS are more likely to come back

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after treatment.

Estrogen receptor (ER) and progesterone receptor (PR) status

Receptors are proteins on the outside surfaces of cells that can attach to certain substances, such as hormones, that circulate in the blood. Normal breast cells and some breast cancer cells have receptors that attach to estrogen and progesterone. These 2 hormones often fuel the growth of breast cancer cells.

An important step in evaluating a breast cancer is to test a portion of the cancer removed during the biopsy (or surgery) for the presence of estrogen and progesterone receptors. Cancer cells may contain neither, one, or both of these receptors. Breast cancers that contain estrogen receptors are often referred to as "ER-positive" cancers, while those containing progesterone receptors are called "PR-positive" cancers. Women with hormone receptor-positive cancers tend to have a better prognosis and are much more likely to respond to hormone therapy than women with cancers without these receptors.

All breast cancers, with the exception of lobular carcinoma in situ (LCIS), should be tested for these hormone receptors at the time of the breast biopsy or surgery. About 2 out of 3 breast cancers contain at least one of these receptors. This percentage is higher in older women than in younger ones.

HER2/neu status

About 1 of 5 breast cancers have too much of a growth-promoting protein called HER2/neu (often just shortened to HER2). This protein is made by cells under the instruction of the HER2/neu gene. Tumors with increased levels of HER2/neu are referred to as "HER2-positive."

Women with HER2-positive breast cancers, have too many copies of the HER2/neu gene (known as gene amplification), resulting in greater than normal amounts of the HER2/neu protein (known as overexpression of HER2/neu). These cancers tend to grow and spread more aggressively than other breast cancers.

HER2/neu testing should be performed on all newly diagnosed breast cancers, because HER2-positive cancers are much more likely to benefit from treatment with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin) and lapatinib (Tykerb). See the section, "How is breast cancer treated?" for more information on these drugs.

Testing of the biopsy or surgery sample is usually done in one of two ways:

immunohistochemistry (IHC): In this test, special antibodies that identify the HER2/neu protein are applied to the sample, which cause cells to change color if many copies are present. This color change can be seen under a microscope.

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fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.

Many breast cancer specialists feel the FISH test is more accurate than IHC. However, it is more expensive and takes longer to get the results. Newer test methods are now becoming available as well (see "What's new in breast cancer research and treatment?").

Tests of ploidy and cell proliferation rate

The ploidy of cancer cells refers to the amount of DNA they contain. If there's a normal amount of DNA in the cells, they are said to be diploid. If the amount is abnormal, then the cells are described as aneuploid. Although tests of ploidy may help determine prognosis, they rarely change treatment and are considered optional. They are not usually recommended as part of a routine breast cancer work-up.

The S-phase fraction is the percentage of cells in a sample that are replicating (copying) their DNA. DNA replication means that the cell is getting ready to divide into 2 new cells. The rate of cancer cell division can also be estimated by a Ki-67 test. A high S-phase fraction or Ki-67 labeling index means that the cancer cells are dividing more rapidly, which indicates a more aggressive cancer.

Tests of gene patterns

Researchers have found that looking at the patterns of a number of different genes at the same time (sometimes referred to as gene expression profiling) can help predict whether or not an early stage breast cancer is likely to come back after initial treatment. Two such tests, which look at different sets of genes, are now available.

Oncotype DX®: The Oncotype DX test may be helpful when deciding whether additional (adjuvant) treatment with chemotherapy might be useful in women with certain early stage breast cancers (stage I or II estrogen receptor-positive breast cancers without lymph node involvement) after initial surgical treatment. Recent data has shown it may also be helpful for patients with positive lymph nodes.

The test looks at a set of 21 genes in cells from tumor samples to determine a 'recurrence score', which is a number between 0 and 100:

Women with a recurrence score of 17 or below have a low risk of recurrence. Those with a score of 18 to 30 are at intermediate risk. Women with a score of 31 or more are at high risk.

The test cannot tell for certain if any particular woman will have a recurrence. It is a tool that can be used, along with other factors, to help guide women and their doctors when deciding whether more treatment might be useful.

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MammaPrint®: This test can be used to help determine how likely certain early stage (stage I or II) breast cancers are to recur in a distant part of the body after initial treatment. It can be used for either ER-negative or ER-positive tumors.

The test looks at the activity of 70 different genes to determine if the cancer is 'low risk' or 'high risk'. This may help doctors to decide if further (adjuvant) treatment might be needed.

In order to do a MammaPrint test, the tumor must be collected and stored in a certain way, so the decision to do this test must be made before surgery.

Usefulness of these tests: While some doctors are using these tests (along with other information) to help make decisions about offering chemotherapy, others are waiting for more research to prove they are helpful. Large clinical trials of these tests are now being done. In the meantime, women may want to discuss with their doctors whether or not these tests might be appropriate.

Detailed Guide: Breast CancerHow Is Breast Cancer Staged?

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The stage describes the extent of the cancer in the body. It is based on whether the cancer is invasive or non-invasive, the size of the tumor, how many lymph nodes are involved, and if it has spread to other parts of the body. The stage of a cancer is one of the most important factors in determining prognosis and treatment options.

Staging is the process of finding out how widespread a cancer is when it is diagnosed. Depending on the results of your physical exam and biopsy, your doctor may want you to have certain imaging tests such as a chest x-ray, mammograms of both breasts, bone scans, computed tomography (CT) scans, magnetic resonance imaging (MRI), and/or positron emission tomography (PET) scans (see below). Blood tests may also be done to evaluate your overall health and help find out if the cancer has spread to certain organs.

Imaging tests to look for breast cancer spread

Once breast cancer is diagnosed, one or more of the following tests may be done.

Chest x-ray

This test may be done to see whether the breast cancer has spread to your lungs.

Mammogram

If they haven't been done already, more extensive mammograms may be done to get more thorough views of the breasts. This test is described in the section "How is breast cancer diagnosed?"

Bone scan

A bone scan can help show whether a cancer has metastasized (spread) to your bones. It can be more useful than standard x-rays because it can show all of the bones of the body at the same time.

For this test, a small amount of low-level radioactive material is injected into a vein (intravenously, or IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.

Areas of bone changes appear as "hot spots" on your skeleton -- that is, they attract the radioactivity. These areas may suggest the presence of metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish between these conditions, your cancer care team may use other imaging tests such as simple x-rays or CT or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.

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Computed tomography (CT) scan

The CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. In women with breast cancer, this test is most often used to look at the chest and/or abdomen to see if the cancer has spread to other organs.

Before the CT scan, you may be asked to drink a contrast solution and/or receive an IV (intravenous) line through which a contrast dye is injected. This helps better outline structures in your body.

The contrast may cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions like trouble breathing or low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in while the pictures are being taken.

In recent years, spiral CT (also known as helical CT) has become available in many medical centers. This type of CT scan uses a faster machine. The scanner part of the machine rotates around the body continuously, allowing doctors to collect the images much more quickly than with standard CT. This lowers the chance of "blurred" images occurring as a result of breathing motion. It also lowers the dose of radiation received during the test. The biggest advantage may be that the image "slices" are thinner, which gives more detailed pictures and lets doctors to look at suspicious areas from different angles.

CT guided needle biopsy: CT scans can also be used to precisely guide a biopsy needle into a suspected area of cancer spread. For this procedure, you remain on the CT scanning table while a radiologist advances a biopsy needle through the skin and toward the location of the mass. CT scans are repeated until the doctors are sure that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8-inch in diameter) is then removed and sent to be looked at under a microscope.

Magnetic resonance imaging (MRI) scan

This test is described in the sections "Can breast cancer be found early" and "How Is Breast Cancer Diagnosed?" as an imaging test of the breast. Traditionally, MRI scans have been used to look for cancer that has spread to various parts of the body, just like

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CT scans. MRI scans are particularly helpful in looking at the brain and spinal cord.

MRI scans use radio waves and very strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material called gadolinium is often injected into a vein before the scan to better see details.

MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Second, you have to lie inside a narrow tube, which is confining and can upset people with claustrophobia (a fear of enclosed spaces). Newer, "open" MRI machines can sometimes help with this if needed. The machine also makes buzzing and clicking noises that you may find disturbing. Some centers provide headphones with music to block this out.

Ultrasound

This test is described in the section "How is breast cancer diagnosed?" as an imaging test of the breast. But ultrasound can also used to look for cancer that has spread to some other parts of the body.

Ultrasound tests use of sound waves and their echoes to produce a picture of internal organs or masses. A small microphone-like instrument called a transducer sends out sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image that is shown on a computer screen. This test is painless and does not expose you to radiation.

Abdominal ultrasound can be used to look for tumors in your liver or other abdominal organs. When you have an abdominal ultrasound exam, you simply lie on a table and a technician moves the transducer over the skin overlying the part of your body being examined. Usually, the skin is first lubricated with gel.

Positron emission tomography (PET) scan

For a PET scan, glucose (a form of sugar) that contains a radioactive atom is injectedinto the bloodstream. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. After about an hour, a special camera is used to create a picture of areas of radioactivity in the body.

PET is useful when your doctor thinks the cancer may have spread but doesn't know where. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about your whole body. Some newer machines are able to perform both a PET and CT scan at the same time (PET/CT scan). This allows the radiologist to compare areas of higher radioactivity on the PET with the appearance of that area on the CT.

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This test can be used along with a mammogram, especially when looking for cancer in axillary lymph nodes. So far, most studies show it isn't very sensitive in finding small deposits of cancer in lymph nodes, although it can find big ones.

The American Joint Committee on Cancer (AJCC) TNM System

A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread. The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system.

The stage of a breast cancer can be based either on the results of physical exam, biopsy, and imaging tests (called the clinical stage), or on the results of these tests plus the results of surgery (called the pathologic stage). The staging described here is the pathologic stage, which includes the findings after surgery, when the pathologist has looked at the breast mass and nearby lymph nodes. Pathologic staging is likely to be more accurate than clinical staging, as it allows the doctor to get a firsthand impression of the extent of the cancer.

The TNM staging system classifies cancers based on their T, N, and M stages:

T stands for tumor (its size and how far it has spread within the breast and to nearby organs).

N stands for spread to lymph nodes (bean-shaped collections of immune system cells that help fight infections and cancers).

M is for metastasis (spread to distant organs).

Additional letters or numbers appear after T, N, and M to give more details about the tumor, lymph nodes, and metastasis:

The letter T followed by a number from 0 to 4 describes the tumor's size and spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.

The letter N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected.

The letter M followed by a 0 or 1 indicates whether the cancer has spread to distant organs -- for example, the lungs or bones.

Breast cancer T, N, and M categories

Primary tumor (T):

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TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass) T1: Tumor is 2 cm (3/4 of an inch) or less across. T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across. T3: Tumor is more than 5 cm across. T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.

Nearby lymph nodes (N) (based on looking at them under a microscope):

NX: Nearby lymph nodes cannot be assessed (for example, removed previously). N0: Cancer has not spread to nearby lymph nodes. N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy. N2: Cancer has spread to 4 to 9 axillary lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes. N3: One of the following applies:

- Cancer has spread to 10 or more axillary lymph nodes. - Cancer has spread to the lymph nodes under the clavicle (collar bone). - Cancer has spread to the lymph nodes above the clavicle. - Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes. - Cancer involves 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

Metastasis (M):

MX: Presence of distant spread (metastasis) cannot be assessed. M0: No distant spread. M1: Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver.)

Breast cancer stage grouping

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping. Cancers with similar stages tend to have a similar outlook and thus are often treated in a similar way. Stage is expressed in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage). Non-invasive cancer is listed as stage 0.

Stage 0: Tis, N0, M0: This is ductal carcinoma in situ (DCIS), the earliest form of breast cancer. In DCIS, cancer cells are still within a duct and have not invaded deeper into the

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surrounding fatty breast tissue. Lobular carcinoma in situ (LCIS) is sometimes classified as stage 0 breast cancer, but most oncologists believe it is not a true breast cancer. In LCIS, abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules. Paget disease of the nipple (without an underlying tumor mass) is also stage 0. In all cases the cancer has not spread to lymph nodes or distant sites.

Stage I: T1, N0, M0: The tumor is 2 cm (about 3/4 of an inch) or less across and has not spread to lymph nodes or distant sites.

Stage IIA: T0, N1, M0 / T1, N1, M0 / T2, N0, M0: One of the following applies:

The tumor is 2 cm or less across (or is not found) and has spread to 1 to 3 axillary lymph nodes.

The tumor is 2 cm or less across (or is not found) and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

The tumor is 2 cm or less across (or is not found), has spread to 1 to 3 axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

The tumor is larger than 2 cm across and less than 5 cm but hasn't spread to the lymph nodes.

The cancer hasn't spread to distant sites.

Stage IIB: T2, N1, M0 / T3, N0, M0: One of the following applies:

The tumor is larger than 2 cm and less than 5 cm across. It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

The tumor is larger than 5 cm across but does not grow into the chest wall or skin and has not spread to lymph nodes.

The cancer hasn't spread to distant sites.

Stage IIIA: T0-2, N2, M0 / T3, N1-2, M0: One of the following applies:

The tumor is not more than 5 cm across (or cannot be found). It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.

The tumor is larger than 5 cm across but does not grow into the chest wall or skin. It has spread to 1 to 9 axillary nodes, or to internal mammary nodes.

The cancer hasn't spread to distant sites.

Stage IIIB: T4, N0-2, M0: The tumor has grown into the chest wall or skin, and one of the following applies:

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It has not spread to the lymph nodes. It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are

found in internal mammary lymph nodes on sentinel lymph node biopsy. It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal

mammary lymph nodes.

The cancer hasn't spread to distant sites.

Inflammatory breast cancer is classified as stage IIIB unless it has spread to distant lymph nodes or organs, in which case it would be stage IV.

Stage IIIC: T0-4, N3, M0: The tumor is any size (or can't be found), and one of the following applies:

Cancer has spread to 10 or more axillary lymph nodes. Cancer has spread to the lymph nodes under the clavicle (collar bone). Cancer has spread to the lymph nodes above the clavicle. Cancer involves axillary lymph nodes and has enlarged the internal mammary

lymph nodes. Cancer has spread to 4 or more axillary lymph nodes, and tiny amounts of cancer

are found in internal mammary lymph nodes on sentinel lymph node biopsy.

The cancer hasn't spread to distant sites.

Stage IV: T0-4, N0-3, M1: The cancer can be any size and may or may not have spread to nearby lymph nodes. It has spread to distant organs (the most common sites are the bone, liver, brain, or lung), or to lymph nodes far from the breast.

If you have any questions about the stage of your cancer and what it might mean in your case, be sure to ask your doctor.

Breast cancer survival rates by stage

The numbers below come from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and are based on women who were diagnosed with breast cancer between 1988 and 2001. There are some important points to note about these numbers:

The 5-year survival rate refers to the percentage of patients who live at least 5 years after being diagnosed with cancer. Many of these patients live much longer than 5 years after diagnosis. Five-year relative survival rates (such as the numbers below) take into account the fact that some patients with cancer will die from other causes. They are considered to be a more accurate way to describe the outlook for patients with a particular type and stage of cancer.

The SEER database does not divide survival rates by substages, such as IIA and

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IIB. The rates for these substages are likely to be close to the rate for the overall stage. For example, the survival rate for stage IIA is likely to be slightly higher than that listed for stage II, while the survival rate for stage IIB would be expected to be slightly lower.

These numbers were taken from patients treated several years ago. Although they are among the most current numbers we have available, improvements in treatment since then mean that the survival rates for people now being diagnosed with these cancers may be higher.

While survival statistics can sometimes be useful as a general guide, they may not accurately represent any one person's prognosis. A number of other factors, including other tumor characteristics and a person's age and general health, can also affect outlook. Your doctor can tell you how these numbers may apply to you, as he or she is familiar with the aspects of your particular situation.

Stage 5-year Relative Survival Rate

0 100%

I 100%

II 86%

III 57%

IV 20%