Breast Cancer Diagnosis Methods: Screening, Biopsy, and Staging

Breast Cancer Screening Programs

Screening typically involves mammography, often starting around age 50, with the goal of detecting emerging cancer (Ca).

• Sensitivity: > 85%
• Specificity: > 90%

Early Detection Recommendations

Monthly breast self-examination (BSE) is generally not recommended due to potential issues:

• Causes anxiety.
• High rate of false positives (FP+).
• May lead to unnecessary biopsies and expense.

Recommendations by Age Group

• Women 35–40 years: Annual clinical breast examination and bilateral mammography (only if clinically indicated).
• Women over 40 years: Annual clinical breast examination and mammography every 1–2 years.

Clinical Presentation and Diagnosis

Clinical diagnosis typically follows two pathways:

1. Asymptomatic Women: Suspicious findings identified during mammography screening.
2. Symptomatic Women: Patient discovers a symptom and consults a doctor.

Key Clinical Symptoms

Suspicious symptoms that prompt clinical investigation include:

• Painless breast lump.
• Breast pain.
• Bloody discharge from the nipple (telorrhea).
• Nipple retraction.

Radiographic Diagnosis: Mammography Findings

Radiographic evaluation often follows clinical suspicion (palpation and inspection, searching for nodes or lymph involvement).

Suspicious Mammography Indicators

• More than 5 microcalcifications in an area less than 1 cm².
• Irregular and spiculated nodular densities.
• Architectural distortion.

These findings typically necessitate further investigation, such as a biopsy.

Achieving Diagnosis of Certainty

Biopsy Methods

Methods used to obtain a definitive diagnosis include:

• Fine Needle Aspiration (FNA).
• Core Needle Biopsy.
• Ultrasound-Guided Biopsy.
• Stereotactic Biopsy (Directed Biopsy).

The Triple Diagnosis Approach

The Triple Diagnosis approach is highly effective, surpassing the efficacy of individual tests or combinations of two tests. It consists of three components:

1. Clinical Examination.
2. Imaging (Mammography, Breast Ultrasound, or MRI).
3. Pathological Assessment (FNA or Needle Biopsy).

Molecular and Histological Classification

Molecular Studies (Receptor Status)

• Immunohistochemical study of hormone receptors (Estrogen and Progesterone) and HER-2 status.
• Study of HER-2 gene amplification using Fluorescence In Situ Hybridization (FISH).

Histological Diagnosis of Breast Cancer

The majority of breast cancers are Adenocarcinomas (85%).

Major Types (Adenocarcinoma)

• Ductal: In situ or Infiltrating.
• Lobular: In situ or Infiltrating.

Other Types (15%)

• Mucinous
• Papillary
• Medullary
• Tubular
• Adenocystic

Diagnosis of Extension (Staging)

The required extension studies (metastatic workup) depend on the pathological stage:

• Pathological Stages 0 and I: Bone scan, abdominal ultrasound, and chest radiography are not indicated.
• Pathological Stage II: Bone scan is indicated as part of the extension study. Abdominal ultrasound and chest radiography are not indicated.
• Pathological Stages III and IV: Bone scan, abdominal ultrasound, and chest radiograph are all indicated.

Special Considerations for Extension Studies

In women whose therapeutic options are restricted (e.g., limited to Tamoxifen or hormone therapy) or where other treatments are contraindicated due to age or other factors, it is recommended to perform a bone scan, abdominal ultrasound, and chest radiograph as part of the extension study.