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Innovation and clinical specialities: oncology
International Union Against Cancer) and the American Joint
Committee on Cancer (AJCC). Tables 2 and 3 show the latest
TNM staging for Breast Cancer (AJCC classification (6th edition or
revision) 55 , which incorporates both clinical information and
changes related to the growing use of new technology (e.g.,
sentinel lymph node biopsy, immunohistochemical staining,
reverse transcriptase-polymerase chain reaction). Patients with
bilateral or multicentric breast cancer are staged according to the
size of the largest tumor.
Diagnosis
Examination
Early breast cancer causes no symptoms and is usually painless.
The commonest symptom is a painless lump in the breast.
Examination of the breast should be done in such a way to show
respect for the privacy and comfort of the patient. A systematic
approach to breast examination is important. Initial examination
should start with the patient in an upright position with careful
visual inspection of masses, skin and nipple changes, and
asymmetries. Palpation should be done to include all the breast
quadrants, the nipple-areola complex, the axillary tail and the
axilla. Simple maneuvers like stretching the arms high above the
head, tensing the pectoralis muscles may help accentuate
asymmetries and dimpling.
Other less frequent presenting signs and symptoms of breast
cancer include (1) breast enlargement or asymmetry; (2) nipple
changes, retraction, or discharge, including Paget’s disease; (3)
ulceration or erythema of the skin of the breast including
inflammatory carcinoma; (4) an axillary mass; and (5) systemic
symptoms such as fatigue, cough, ascites or new musculoskeletal
discomfort.
Imaging
Mammography, Ductography, Ultrasonography, MRI are imaging
techniques useful in the screening and diagnosis of breast cancer.
Mammography is the most useful test to differentiate between
benign and malignant lesions and is the one that is recommended
for breast cancer screening. Specific mammography features that
suggest a diagnosis of a breast cancer include a solid mass with
or without stellate features, asymmetric thickening of breast
tissues, and clustered microcalcifications Mammography may also
be used to guide interventional procedures, including needle
localization and needle biopsy.
Xeromammography techniques are identical to those of
mammography with the exception that the image is recorded on a
xerography plate, which provides a positive rather than a negative
image Details of the entire breast and the soft tissues of the chest
wall may be recorded with one exposure.
Ductography and ductoscopy
Mammary ductoscopy (MD) is a newly developed endoscopic
technique that allows direct visualization and biopsy examination
of the mammary ductal epithelium where most cancers originate.
When combined with ductal lavage and cytology , it may reveal
early carcinoma. 56-59 The primary indication for ductography is
nipple discharge, particularly when the fluid contains blood.
Radiopaque contrast media is injected into one or more of the
major ducts and mammography is performed. Intraductal
papillomas are seen as small filling defects surrounded by contrast
media. Cancers may appear as irregular masses or as multiple
intraluminal filling defects.
Ultrasonography is an important method of resolving equivocal
mammography findings, defining cystic masses, and demonstrating
the echogenic qualities of specific solid abnormalities.
Ultrasonography is used to guide fine-needle aspiration biopsy,
core-needle biopsy, and needle localization of breast lesions. It is
highly reproducible and has a high patient acceptance rate, but
does not reliably detect lesions that are 1 cm or less in diameter
Table 2: Diagnosis and pathology
LEVEL OF RESOURCE CLINICAL PATHOLOGY IMAGING AND LABORATORY TESTS
Basic History Interpretation of biopsies
Physical examination
Clinical breast examination
Cytology or pathology report
Surgical biopsy
Fine-needle aspiration
describe tumor size,
lymph node staue,
hiatologic type, tumor grade
Limited Core needle biopsy Determination and reporting Diagnostic breast ultrassound+
Image-guided sampling of ER and PR statue diagnostic mammography
(ultrasonographic+mammographic)
Plain chest mammography
Determination and reporting
Liver ultrasound
of margin satue
Blood chemistry profile/CBC
Enhanced Preoperative needle localization under On-site cytopathologist Diagnostic mammography
mammographic or ultrasound guidance
Bone scan
Maximal Stereotactic biopsy HER2/new statue CT scanning, PET
Sentinal node biopsy IHC ataining of aentinel nodes MIBI scan, breast MRI
for cytokeratin to detect
micrometastaes
CBC, coomplete bloodcount; CT, computed tomography; ER, estrogen recaptor; IHC, immunohistochemistry; MIBI, 99mto-sastamibi; MRI, magnetic resonance imaging;
PET, positron emission tomography; PR, progerterone receptor
94 Hospital and Healthcare Innovation Book 2009/2010