Breast Biopsy

Fine needle aspiration of a breast lump. By Linda Bartlett (Photographer) - This image was released by the National Cancer Institute, an agency part of the National Institutes of Health, with the ID 1973 (image) (next)., Public Domain, https://commons.wikimedia.org/w/index.php?curid=9852520

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Soroush Seifirad, M.D.[2]

## Overview

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Breast biopsy the only definite way to diagnose breast cancer. Hence, every patient with a suspicious lesion in her/his breast needs a biopsy to evaluate the nature of the mass precisely. Nevertheless, a large number of biopsy samples taken from breast lumps are found to be benign.

## Biopsy

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* Lymphadenectomy or lymph node dissection is the surgical removal of one or more groups of lymph nodes. It is almost always performed as part of the surgical management of cancer. In a regional lymph node dissection, some of the lymph nodes in the tumor area are removed; in a radical lymph node dissection, most or all of the lymph nodes in the tumor area are removed.
* During a biopsy, tissues or cells are removed from the body so they can be tested in a laboratory. The pathology report from the laboratory will confirm whether or not cancer cells are present in the sample. [1]

* A breast biopsy is the only definite way to diagnose breast cancer. Most biopsy samples taken from breast lumps are found to be benign (non-cancerous).
* The type of biopsy will depend on whether the lump can be felt (palpable) or not (non-palpable). Ultrasound or computed tomography (CT) scan may be used to guide the biopsy. The types of biopsy that may be used are:

* Fine needle aspiration (FNA)[2]
* Core needle biopsy
* Stereotactic core needle biopsy
* Wire localization biopsy
* Surgical biopsy to remove part of or all of a breast lump or abnormal area

* A biopsy is also done if inflammatory breast cancer is suspected, often including a skin biopsy. A biopsy of the nipple is taken if the doctor suspects Paget disease of the nipple.

As discussed below lymph node dissection would be either with or without sentinel node biopsy.

### With sentinel lymph node biopsy

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For clinical stages I and II breast cancer, axillary lymph node dissection should only be performed after first attempting sentinel node biopsy. Sentinel node biopsy can establish cancer staging of the axilla if there are positive lymph nodes present. It also is less risky than performing lymphadenectomy, having fewer side effects and a much lower chance of causing lymphedema. If cancer is not present in sentinel lymph nodes then the axillary lymph node dissection should not be performed.

If one or two sentinel nodes have cancer which is not extensive, then no axillary dissection should be performed but the person with cancer should have breast-conserving surgery and chemotherapy appropriate for their stage of cancer.

### With sentinel lymph node mapping

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Cancer with various primary sites (breast, melanoma, colorectal, etc.)[3] often metastasize early to the first drainage lymphatic basin. This process is predictable anatomically according to the primary site in the organ and the lymphatic channels. The first nodes (sentinel nodes) can be identified by particulate markers such as lymphazurin, methylene blue, India ink and radio-labeled colloid protein particles injected near the tumor site. The draining sentinel node can then be found by the surgeon and excised for verification by the pathologist if tumor cells are present, and often these tumor cells are few and only easily recognized by careful examination or by using techniques such as special stains, i.e. immunohistochemical. When the sentinel node is free of tumor cells, this is highly predictive of freedom from metastasis in the entire lymphatic basin, thus allowing a full node dissection to be avoided.

The practice of sentinel lymph node mapping has changed the surgical approach in many cancer systems, sparing a formal lymph node dissection for patients with sentinel lymph node negative for tumor and directing a full node dissection for patients with sentinel lymph node positive for tumor metastases. For example in stage II breast carcinoma, using thesentinel lymph node technique, 65% of patients could be spared from a formal node dissection.

Complication

Lymphedema may result from lymphadenectomy. Extensive resection of lymphatic tissue can lead to the formation of a lymphocele.[4]

## Lymph node biopsy

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A lymph node is a small, bean-shaped mass of lymphatic tissue along lymph vessels (tubes through which lymph fluid travels in the body). Lymph nodes store lymphocytes (a type of white blood cell that fights germs, foreign substances or cancer cells) and filters bacteria and foreign substances (including cancer cell biopsy removes lymph nodes during a surgical procedure so they can be examined under a microscope to find out if they contain cancer.

With breast cancer, lymph nodes from under the arm (axilla) are removed. Breast cancer cells can travel through the lymph system, and the first place they may spread is to these lymph nodes. The number of lymph nodes that have cancer helps to determine the stage stage A description of the extent of cancer in the body, including the size of the tumor, whether there are cancer cells in the lymph nodes and whether the disease has spread from its original site to other parts of the body. of breast cancer.

## Axillary lymph node dissection

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Axillary lymph node dissection (ALND) is a surgical procedure to remove the lymph nodes under the arm.

* Most breast cancers require staging with ALND.
* Axillarylymph node dissection is the standard method of checking lymph nodes.

## Sentinel lymph node biopsy

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* The sentinel node is the first lymph node in a chain or cluster of lymph nodes that receive lymph fluid from the area around a tumor. Cancer cells will most likely spread to these lymph nodes. Sentinel lymph node biopsy (SLNB) is the removal of the sentinel node so it can be examined to see if contains cancer cells.
* sentinel lymph node biopsy may be offered to women with breast tumors smaller than 5 cm, and the axillary lymph nodes cannot be felt during an examination by the doctor.
* sentinel lymph node biopsy may not be suitable for women:

* Who had breast surgery or radiation therapy in the past
* With axillary lymph nodes the doctor can feel
* With locally advanced or advanced breast cancer (tumors greater than 5 cm in size)
* With tumors in more than one area in the breast (multifocal tumors)
* With metastatic breast cancer
* Inflammatory breast cancer
* Who have had breast reduction surgery, or have breast implants

Breast lymphatic drainage system. By Don Bliss (Illustrator) - This image was released by the National Cancer Institute, an agency part of the National Institutes of Health, with the ID 4359 (image) (next)., Public Domain, https://commons.wikimedia.org/w/index.php?curid=24052138 A blue stained sentinel lymph node (axilla). Image courtesy of Will Blake. Source:https://en.wikipedia.org/wiki/Sentinel_lymph_node A micrograph showing an adenocarcinoma of the breast (dark pink) in a lymph node (purple) and extending into the surrounding fat (white, chicken-wire appearance). H&E stain. Source: https://en.wikipedia.org/wiki/Sentinel_lymph_node

### Procedure

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* To perform a sentinel lymph node biopsy, the physician performs a lymphoscintigraphy, wherein a low-activity radioactive substance is injected near the tumor. The injected substance, filtered sulfur colloid, is tagged with the radionuclide technetium-99m. The injection protocols differ by the doctor but the most common is a 500 μCi dose divided among 5 tuberculin syringes with 1/2 inch, 24 gauge needles.[2] In the UK 20 megabecquerels of nanocolloid is recommended. The sulfur colloid is slightly acidic and causes minor stinging. A gentle massage of the injection sites spreads the sulfur colloid, relieving the pain and speeding up the lymph uptake. Scintigraphic imaging is usually started within 5 minutes of injection and the node appears from 5 min to 1 hour. This is usually done several hours before the actual biopsy. About 15 minutes before the biopsy the physician injects a blue dye in the same manner. Then, during the biopsy, the physician visually inspects the lymph nodes for staining and uses a gamma probe or a Geiger counter to assess which lymph nodes have taken up the radionuclide. One or several nodes may take up the dye and radioactive tracer, and these nodes are designated the sentinel lymph nodes. The surgeon then removes these lymph nodes and sends them to a pathologist for rapid examination under a microscope to look for the presence of cancer.

* A frozen section procedure is commonly employed (which takes less than 20 minutes), so if neoplasia is detected in the lymph node a further lymph node dissection may be performed. With malignant melanoma, many pathologists eschew frozen sections for more accurate "permanent" specimen preparation due to the increased instances of false-negative with melanocytic staining.[5]

### Clinical advantages

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* There are various advantages to the sentinel node procedure. First and foremost, it decreases lymph node dissections where unnecessary, thereby reducing the risk of lymphedema, a common complication of this procedure.[4]
* Increased attention on the node(s) identified to most likely contain metastasis is also more likely to detect micro-metastasis and result in staging and treatment changes.

### Research advantages

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* As a bridge to translational medicine, various aspects of cancer dissemination can be studied using sentinel node detection and ensuing sentinel node biopsy.
* Tumor biology pertaining to metastatic capacity, mechanisms of dissemination, the EMT-MET-process (epithelial-mesenchymal transition) and cancer immunology are some subjects that can be more distinctly investigated.

### Disadvantages

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* However, the technique is not without drawbacks.
* Failure to detect cancer cells in the sentinel node can lead to a false-negative result while there may still be cancerous cells in the lymph node basin.
* In addition, there is no compelling evidence that patients who have a full lymph node dissection as a result of a positive sentinel lymph node result have improved survival compared to those who do not have a full dissection until later in their disease when the lymph nodes can be felt by a physician. Such patients may be having an unnecessary full dissection, with the attendant risk of lymphedema.[4]

## Reference

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1. ↑ Breast cancer. Canadian Cancer Society (2015) http://www.cancer.ca/en/cancer-information/cancer-type/breast/signs-and-symptoms/?region=on#ixzz3xScycfqv Accessed on January 16, 2016
2. ↑ 2.0 2.1 Mišković J, Zorić A, Radić Mišković H, Šoljić V (2016) Diagnostic Value of Fine Needle Aspiration Cytology for Breast Tumors Acta Clin Croat 55 (4):625-628. DOI:10.20471/acc.2016.55.04.13 PMID: 29117654
3. ↑ Morton DL, Cochran AJ, Thompson JF, Elashoff R, Essner R, Glass EC et al. (2005) Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial. Ann Surg 242 (3):302-11; discussion 311-3. PMID: 16135917
4. ↑ 4.0 4.1 4.2 Fu MR (2014) Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management. World J Clin Oncol 5 (3):241-7. DOI:10.5306/wjco.v5.i3.241 PMID: 25114841
5. ↑ Poling JS, Tsangaris TN, Argani P, Cimino-Mathews A (2014) Frozen section evaluation of breast carcinoma sentinel lymph nodes: a retrospective review of 1,940 cases. Breast Cancer Res Treat 148 (2):355-61. DOI:10.1007/s10549-014-3161-x PMID: 25318925