Diagnosis

Stereotactic Biopsy

New biopsy techniques involve what is termed as minimally invasive management. This either uses stereotactic or ultrasound guided biopsy.3 Stereotactic machines biopsy microcalcifications or a nonpalpable mass on a geometric X, Y, and Z axis.4 Core biopsies are obtained by at least a 14 gauge needle. At least five cores are needed to perform an adequate tissue sample.5 A clip is usually placed at the biopsy site for future imaging and possible therapy.

Limitations with this technique include a lesion close to the skin or nipple or a patient with small breasts or a patient that is uncooperative. A very important point with stereotactic biopsy is that a diagnosis of atypia or DCIS cannot be made.6 This lesion needs to be openly excised to check for invasion.

An older option of diagnosis of nonpalpable lesion is needle localization by mammogram or ultrasound. The tissue removed should be sent to radiology or pathology to confirm removal of the lesion. This, however, requires an operative procedure and is more disfiguring to the breast.

Metastasis

Metastatic spread is by different pathways. The main metastatic area is to the ipsilateral axillary nodes as it drains 75% of the breast. Parasternal nodes drain the medial 25% of the breast. Vascular spread sends metastasis to the lungs, brain, and spine.

Preoperative evaluation includes:

1. LFT to check liver involvement

2. CXR to check for lung mets

3. Abdominal CT is performed if the LFTs are elevated

4. Bone scan is performed if there is elevated calcium or the patient has bone pain

If patients have metastatic disease to the bone, they may present with hypercal-cemia. The treatment of this involves hydration, a loop diuretic like Lasix, and a long term biphosphonate (pamidronate) IV. If the patient presents with metastatic disease, no surgery is preformed and comfort measures only are invoked. If spinal cord compression syndromes present then dexamethasone is given and the patient may require spinal stabilization.

References

1. Dershaw DD. Mammographic screening of the high-risk woman. AJS 2000; 180:288-289.

2. Lucassen A, Watson E, Eccles D. Advice about mammography for a young woman with a family history if breast cancer. BMJ 2001; 1040-1042.

3. Smith DN, Christian R, Meyer JE. Large-core needle biopsy of nonpalpable breast cancers. Arch Surg 1997; 132:256-259.

4. Dershaw DD, Liberman L. Stereotactic breast biopsy: Indications and results. Oncology 1998; 12(6):907-922.

5. Rich PM, Michell MJ, Humphreys S et al. Stereotactic 14 G core biopsy of nonpalpable breast cancer: What is the relationship between the number of core samples taken and the sensitivity for detection of malignancy? Clin Rad 1999; 54:384-389.

6. Brem DF, Behrndt S, Sanow et al. Atypical ductal hyperplasia: Histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy. AJR 1999; 172:1405-1406.

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