Diagnosed


 * [[image:Women.jpg]]

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: 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.
 * 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.

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, 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.

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 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.
 * Magnetic resonance imaging (MRI) of the breast**

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.
 * Breast ultrasound**

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 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?"
 * Ductogram**

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.
 * Other tests**

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 and Nipple Aspiration**

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 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.

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.
 * 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 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.
 * Fine needle aspiration 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.
 * Core needle biopsy**

Larger core biopsies: Two newer stereotactic biopsy methods can remove more tissue than a core 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 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).
 * 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**
 * Surgical (open) biopsy**

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.