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Innovation and clinical specialities: oncology
Biopsy
Pathologic diagnosis of a breast lesion can be achieved using a
number of biopsy techniques. With a larger biopsy sample, greater
accuracy and more information are obtained, but this is at the
expense of increased invasiveness. Ideally, needle biopsies should
be performed after imaging to help prevent distortions of imaging
due to hematoma. The various needle biopsy techniques can be
divided into two groups:
✚ 1. Fine needle aspiration will provide cytology which will allow
a diagnosis of malignant cells but will not differentiate between
in situ or invasive disease.
✚ 2. Tissue biopsy for histology which include Tru cut biopsy,
Biopty cut, Mammotome. These relatively larger tissue samples
will allow the diagnosis of invasive versus in situ cancer.
Table 4 compares the accuracy of needle biopsy techniques.
Open Biopsy (Excision or Incision biopsy) The ultimate diagnostic
biopsy is open biopsy of a lesion, normally performed under
general or local anesthetic. Open excisional biopsy should be
reserved for lesions for which some doubt remains regarding
diagnosis after less invasive assessment or for benign lesions that
the patient wants removed. A wide clearance of the lesion is usually
not the goal in diagnostic biopsies, thus avoiding unnecessary
distortion of the breast. It is also useful for excision of
mammographic lesions when percutaneous biopsy has failed or is
equivocal. Where frozen section is available, open excisional biopsy
may be performed at the same time the as definitive breast cancer
surgery. Incisional biopsy is used only in cases where the lesion is
very large and a percutaneous biopsy has been unsuccessful.
Screening
Annual screening mammography has been demonstrated to
reduce breast cancer mortality among women older than 50 years
by 20 –39%. The benefit in younger women is not yet established.
For Caucasian women aged 40–49, the results of RCTs are
consistent in showing no benefits at 5–7 years after entry, a
marginal benefit at 10–12 years, and unknown benefit thereafter.
This is primarily because when used as a screening tool, the
detection rate per screened individual is lower because of denser
breasts and an overall lower incidence. The controversy over the
effectiveness of screening mammography among younger women
(i.e., 40–49 years) has led to varying recommendations about its
use for this age group. In patients with high risk factors a yearly
mammography assessment from the age of 40 years is
advisable. 65-67 Considering the younger demographic pattern of
Breast Cancer in Africa, it is not clear what role screening
mammography should have in Africa.
Other methods of early breast cancer screening like Self Breast
Examination and Clinical Breast Examination have not been
demonstrated to improve mortality in patients; rather SBE has
resulted in more breast biopsies due to false positive results, more
physician visits and apprehension in patients 68 . It is pertinent to
state that most of the studies that evaluated the role of SBE and
CBE have been done in developed societies where cancers are
small at diagnosis and this may not be relevant in Africa where the
majority of patients present late. Incorporation of Breast
Awareness programmes and health education into the Primary
Health Care of African countries may very well be a useful option
to allow for a diagnosis at an earlier stage. Cultural attitudes play
important roles in the acceptance of screening programmes. 69
Treatment
Treatment strategy will depend on the stage of the disease.
In situ breast cancer (DCIS and LCIS)
LCIS: Observation alone with or without tamoxifen is the preferred
option for women diagnosed with LCIS because their risk of
developing invasive carcinoma is relatively low (approximately 21%
over 15 years) and is equal in both breast.. 70 Follow-up of patients
with LCIS includes physical examinations every 6 to 12 months for
5 years and then annually. Annual diagnostic mammography is
recommended in patients being followed with clinical observation.
DCIS: Treatment options for DCIS are mastectomy, breastconserving
surgery (BCS) plus radiotherapy or BCS alone. The
goal of treatment for DCIS is to reduce local recurrence, because
50% of the time that DCIS recurs it recurs as an invasive cancer.
Factors that may modify treatment are:
✚ the grade of the lesion, with higher-grade lesions more likely to
recur in a short time;
✚ the youth of the patient, with many more years at risk for
recurrence and
✚ the size of the lesion.
For years the traditional surgical management of DCIS was
mastectomy, with or without axillary dissection. Breast
conservation technique and irradiation is now a preferred
alternative where local breast radiation is available. Only small, low
grade DCIS that has been excised with a large margin may be
considered for BCS alone. Axillary lymph node staging is
discouraged in women with apparent pure DCIS. However, a small
proportion of patients with apparent pure DCIS will be found to
have invasive cancer at the time of their definitive surgical
procedure which will require a further axillary dissection. 71 Addition
of Tamoxifen reduces the risk of developing contralateral breast
cancer. 72,73 . Follow-up of women with DCIS includes a physical
examination every 6 months for 5 years and then annually, as well
as yearly diagnostic mammography.
Early breast cancer (stages I and II or T1-3N0-1 M0):
Staging for metastatic disease is standard for most patients
diagnosed with early breast cancer and include a chest X-ray,
bone scan and ultrasound of the abdomen. If negative, treatment
intent is curative, and involve modalities that fight the cancer
locally (surgery and radiation) and systemically (chemotherapy and
endocrine therapy).
Loco-regional treatment:
Local treatment requires the treatment of the entire breast and the
axillary lymph nodes with surgery, radiation, or a combination of
both. Surgery can be breast conservation therapy (BCT) and
axillary staging (SLNB or axillary dissection) or simple or total
mastectomy with axillary staging (modified radical mastectomy).
The surgical procedure for the excision of the breast in BCT
goes by several names (Partial mastectomy, tylectomy, segmental
resection, quadrantectomy or lumpectomy).
The goal of breast-conserving surgery is to minimize the risk of
local recurrence while leaving the patient with a cosmetically
acceptable breast. The selection of BCT versus mastectomy
depends on the size of the tumor relative to the rest of the breast
96 Hospital and Healthcare Innovation Book 2009/2010