DIAGNOSTICS PROCEDURES

FINE NEEDLE ASPIRATION (FNA)

A thin needle is put into the lesion in the breast cells are aspirated and smeared onto a glass slide. With coloring methods the cells can be identified by a cytologist. Note, only the pathologist can see individual cells and cannot make a complete diagnoses. The answer can only be cancerous or non-cancerous cells.

This an incomplete diagnoses and cannot be used to plan treatment. It can also happen that no cancer cells are seen on the smear due to technical reasons, and the smear is false negative. You can see the danger of relying on FNA for any diagnoses of breast lumps! More so, if the needle was placed without ultrasound guidance.

I must stress this to all women, and doctors, dealing with breast masses. – A reliable diagnoses can only be made by doing a thick needle CORE biopsy by an experienced radiologist and under ultrasound guidance.

In most cases a core biopsy must be done after FNA, so why do it, causing a lot of stress and extra expense for the patient?

FNA has a definite place when it is done with ultrasound guidance; eg. To see whether glands are affected by cancer cells where you have already diagnosed Breast Cancer; in other lesions elsewhere, like in the thyroid where core biopsy could be a bleeding mass with dangerous structures around.

CORE BIOPSY

The diagnosis of breast cancer today, is made by doing a thick needle core biopsy before any surgery is contemplated!!

A women should not allow an incision (surgical, open) biopsy to be done on her breast mass / lump. Open surgical biopsy should be laid to rest (dead) in antiquity. The reasons for this will become clear to everyone, below.

It can be equated to a General going into battle with the enemy without knowing the battlefield, strength of manpower, ammunition, and fire power to take with him.  He will kill his men.

TECHNIQUE

A cutting needle is placed into a lesion in the breast using ultrasound guidance. A core of tissue is obtained from the mass you want to examine.  Local anesthetic is used and the procedure should be painless. It is done outside of a hospital in the ultrasound room of the radiologist. It is inexpensive (about R1 700 medical aid tariff) and with a low complication rate, in experienced hands. No general anesthetic is needed. No stitches, and very little bleeding. At the most a bluish bruise can develop.

The tissue core is sent to the pathologist. He / she now has a piece of tissue to work with. Many tests are done on this tissue core.

The exact histological diagnoses, with grading and gene typing of the tumor, are obtained within 2 – 4 days. This is of utmost importance for future treatment planning before any surgery is done. The importance if this will become clear when you read BREAST CANCER and TREATMENT.

The expertise to do core biopsies of breast lesions should be available at all mammography and breast care facilities. If a radiology department is embarking on mammography and is not able to do breast biopsies for diagnoses, it is substandard and should not be doing mammography. Such a centre will not qualify as a breast care centre in other countries.  If not available, too many unnecessary open surgical biopsies are forced onto the surgeon and patients.

WHY IS CORE BIOPSY SO ESSENTIAL?

1)        The correct diagnoses are made and the appropriate surgery can be planned beforehand.

2)        The tumor is avoided (not cut into) and completely removed.

3)        SLN mapping is planned and done before the operation is started.

4)        A single procedure under general anesthetic is done instead of two procedures which would be needed if the surgical excision biopsy revealed a cancer diagnoses.

5)        In the case of large tumors, we will be able to start pre-operative systemic treatment (PST) to shrink the tumor size and to do surgery at a later stage. Smaller tumors need a smaller piece of breast to be removed and a mastectomy is avoided.

6)        The surgical procedure can be discussed, in detail, with the patient and her approval obtained before operating.

7)        Reconstruction surgery can be planned to be done at the same time, under the same anesthetic.

8)        The patient, and her family, is saved from the trauma of not knowing what to expect after the operation.

WHY SHOULD INCISION / SURGICAL BIOPSY BE AVOIDED?

1) The surgeon does not have a cancer diagnoses, and may do the wrong surgical planning and approach.

2) The tumor is often not excised wide enough and is often not completely removed. This then leads to a second operation which often results in a mastectomy. The surgeon does not know where to find the piece of cancer left behind, and resorts to a mastectomy to correct a wrong procedure that could have been avoided, if histology had been available before the surgery.

3) When a cancer diagnoses is only obtained during surgery, preparations for SLN mapping has not done. This leads to unnecessary aggressive surgery of the axilla, where all the lymph glands are removed. Serious morbidity can result from this.

4) The poor patient is often asked to sign permission for a mastectomy before the biopsy is done, and thus is denied more options and opinions, and a thorough decision making process. Think about the terrible anxiety she, and her family, go through waiting for the completion of the operation.

5) It is not cost effective.

THE BOTTOMLINE IS:

SURGERY OF THE BREAST SHOULD ONLY BE PLANNED AND DONE AFTER HYSTOLOGY OF ANY BREAST LUMP IS OBTAINED WITH CORE NEEDLE BIOPSY.

AXILLA SURGERY AND SLN (SENTINAL LYMPH NODE) MAPPING

In the past, the axilliary lymph glands were often removed unnecessarily.  Axilliary dissection carries a high morbidity. Swelling and pain in the arm is debilitating.  Removing the glands in the armpit was mainly done for staging, and not for treatment.

To make this staging procedure less invasive, Sentinal Lymph Node mapping was developed about ten years ago. It enables the surgeon to remove only the SENTINAL node to check for involvement during the initial (lumpectomy) surgery.

TECHNIQUE

This is planned the day before the operation to remove the tumor.

A little radio-active isotope (Tc.) is injected over the site of the tumor in the breast just under the skin. The isotope follows the lymphatic vessels from the tumor to the specific gland representing that part of the breast in the axilla.  It illuminates this gland on the monitor of a gamma camera and is mapped out by the Nuclear Physician for the surgeon, the day before the operation.

In theatre, the surgeon is now able to detect and remove the Sentinel node only. This is examined in the theatre by the Pathologist. If the gland is found to be clear (not infiltrated by the cancer) the rest of the glands in the axilla are left untouched.

Trials have shown that if the SLN is not involved, the chances of other glands to be infiltrated are small.

This procedure also helps us to decide whether aggressive treatments will be necessary after the surgery (e.g. Chemotherapy)

This procedure is of value and can be done after pre-operative systemic therapy and after failed excision biopsies.

This procedure has paved the way for less invasive surgery of the axilla, which in any case was only for staging and not for treatment.

All patients planning breast surgery should enquire if SLN mapping is available in her hospital, and if the surgeon will make use of it.

ACTIVATED CARBON TATOO AND LOCALISATION

Internal breast tattoo

Post lumpectomy small breast

Since mammography and ultrasound became more available, smaller and clinically impalpable tumors have been detected. How can the surgeon remove these small cancers if they are not being felt by his hand?

A method to show him these cancers had to be, and was, developed.

Since 1986 we experimented with different methods. I used the hook wire method and found it to be impractical. The hook wire must be placed in the breast the morning of the operation and dangles out of the patient’s breast and is often displaced, the surgeon finds it difficult to find the tumor.

Then I tried the radio-active seed method, which I found to be expensive and gamma probes to detect the seed not readily available in all hospitals.

I then concluded with the activated carbon tattoo method which was already described by Azevedo in 1987.

TECHNIQUE

The tumor is localized with ultrasound or mammography, a needle is placed in the tumor and a small (1 cc) volume of an activated carbon suspension is left behind in and around the tumor.  It leaves a permanent black spot in the breast for future spotting and excision by the surgeon. The needle tract and skin is also marked for the surgeon to find in the future for the planned excision.

This is a very easy and cheep method which the surgeons report to be accurate and technically easy to find the tumor. The carbon does not migrate from the spot where it was deposited. There is no hook wire that can displace and the operation can be done at any time in future. Also, most acceptable to the patient who was always very stressed about the old wire type localization where a wire dangles from her breast until her operation.

The tattoo method also paved the way for cancer treatment by pre-operative systemic therapy. (See elsewhere) In fact, pre-operative systemic therapy cannot successfully be used without such a method. When cancers shrink with pre-operative systemic therapy, they disappear and become impalpable by the surgeons hand.It must be marked by this method for future detection and exision.

More about this under Pre-operative Systemic Therapy – PST.