Diagnosis

The following are tests that may be used to diagnose this type of cancer. 

Up to 90% of breast lumps are benign (not cancer), but an ultrasound, a mammogram and sometimes a biopsy are needed to determine if they are malignant (cancerous). Many benign lumps change size during a menstrual cycle. Doctors may choose to observe a single lump or mass through a menstrual cycle to see if it becomes smaller or disappears, which would show that the lump is not cancer.

Mammography

When a mass or lump is found through touch, or when a screening mammogram shows something unusual, the doctor usually orders a diagnostic mammogram. Diagnostic mammograms often involve more x-ray pictures than a screening mammogram.  Diagnostic mammography can help determine if a lump is probably benign or if a biopsy is necessary to make sure there is no cancer. A mammogram can also be used to guide a needle biopsy to the correct location (this is called “stereotactic core biopsy”)

Ultrasound

When an abnormality is seen on a diagnostic mammogram, an ultrasound is used to determine if there is a mass (lump). Ultrasound can also tell if the mass is fluid filled (a benign cyst) or solid (a possible cancer). Cysts are filled with fluid and are essentially always benign. Solid lumps require biopsies to establish whether they are benign or cancer. Ultrasound is often used to guide the biopsy needle into the suspicious lump.

MRI

MRI’s full role in diagnosing breast cancer has not been defined yet. MRI can also be used to help aid the diagnosis of underlying cancer, when the patient has Paget’s disease, swollen lymph nodes under the arm, AND when both mammograms and ultrasound of the breast are negative but there is still a suspicion of cancer. A biopsy of a breast lump is sometimes done using MRI to guide the needle. A diagnostic MRI is different from a screening MRI.

Biopsies

The Pathology Report Patient Companion Guide was created to help breast cancer patients understand the pathology report and how the test results help guide treatment planning.  Feedback from patients, pathologists, physicians, surgeons and oncologists was used to make this guide clinically accurate and patient friendly. 

A biopsy is the removal of breast tissue for a pathologist to view under a microscope. There are several different types of biopsies.

• Fine needle aspiration (FNA). A small needle is inserted into the lump to remove several cells. FNA can be done in a doctor’s office if the lump can be felt by the doctor or it may require the simultaneous use of an ultrasound, mammogram or MRI to guide the needle. If FNA confirms a cyst, usually no further biopsies are needed. If the fine needle aspiration confirms or is suspicious for a cancer, a further biopsy may be required. A negative finding will also usually be followed by a further biopsy. 
  
• Core biopsies are usually done with the help of an ultrasound (most common), mammogram, or MRI. This ensures the needle is inserted into the area of concern.
  
• Open or excisional biopsy. This is a surgical procedure to remove a lump. Occasionally this is done instead of a core biopsy, or after a fine needle or core biopsy, if a diagnosis is still uncertain. This is usually done using local anaesthetic (freezing the skin), but if necessary it can also be done under general anesthesia (putting a patient to sleep). This is almost always a day-care procedure and does not require overnight stay in hospital. If a lump is not easy to feel by hand, sometimes a mammogram or ultrasound is used to insert a wire into the lump before excisional biopsy, to guide the surgeon to the area of concern.
  

Hormone Receptor Testing / Human Epidermal Growth Factor Receptor 2 (HER2) Testing

This tissue removed at biopsy will be tested by pathologists to determine whether the cancer is sensitive to hormones. This will help determine treatment options.

For more information on tests used to diagnose cancer, see Recommended Websites - Screening and Diagnosis. 

Types & stages

Types

Breast lumps are divided into malignant or non-malignant (benign) conditions.

Malignant tumours are non-invasive (in one spot, called “in situ”) or invasive (invading into the breast cancer fat around the ducts and lobules of the breast). It is very rare for in situ cancers to spread outside the breast. Invasive cancers can spread to the lymph nodes and other areas of the body.

Almost all malignant breast cancers are called adenocarcinomas, which mean these cancers are from the glandular parts of the breast. Depending on what glandular parts of the breast the cancer starts in (which is determined by looking at them under the microscope), they are called ductal carcinoma (75%), lobular carcinoma (15%), and medullary, tubular, scirrhous or other less common types.

Ductal Carcinoma In Situ (DCIS)

• Breast cells are continually exposed to changing levels of hormones, which sometimes can cause cells inside the milk ducts to multiply. These multiplying cells result in a condition called intraductal hyperplasia. If the cells start to look abnormal, this is called "hyperplasia with atypia". The extra cells may block up the duct and begin to look like cancer cells. If that happens, the diagnosis becomes ductal carcinoma in situ (DCIS).

• In DCIS, the cancer cells are confined to the milk ducts. DCIS is considered a pre-cancerous condition. As long as the cells remain inside the duct, DCIS is not invasive. If the cancer cells grow out of the ducts into the breast tissue surrounding the ducts, then it becomes an invasive cancer. DCIS is taken seriously, but it is very treatable and highly curable.

• This condition is not usually found by physical examination. DCIS is most often detected by mammogram if the plugged ducts begin to accumulate calcium deposits.

• Different types or growth patterns of ductal carcinoma in situ (DCIS) are recognizable under the microscope. Pathologists may give the DCIS additional descriptive names depending on how they appear under the microscope, such as ‘papillary, ‘cribriform’ and 'comedo’.

Lobular Carcinoma In Situ (LCIS)

• LCIS, like DCIS, is a non-invasive condition, except the excess cells grow in the lobules of the breast.

• LCIS is a marker for future breast cancer. If LCIS is found, this means that a breast cancer can develop in the future in either breast, not just where the LCIS was found. LCIS occurs less often than DCIS.

• LCIS is considered a risk factor for future breast cancer. If the amount of LCIS is small, it may not mean a much higher risk of invasive breast cancer than for the average person. For people with a lot of LCIS, the risk is higher than average.

• LCIS doesn’t show up reliably on mammography or ultrasound. It is often found when another lump or mammogram abnormality is being investigated by biopsy.

• If LCIS is found, the aim of any treatment is to prevent breast cancer from occurring and to catch any developing cancers as early as possible. The options for patients include:

• regular screening and followup.

• tamoxifen, which can decrease the risk of invasive disease by approximately 50%.

• the removal of both breasts, called prophylactic mastectomy. This is an extreme option and is only rarely recommended. There is more information about this option in the Treatment section.

Invasive Ductal and Lobular Carcinoma

• These are the most common types of breast cancer. Invasive breast cancer means that cancer cells in the ducts or lobules of the breast have broken through the walls of these structures and invaded the surrounding cells.

• If it appears to have started in the ducts, it is called a “ductal carcinoma” and “lobular carcinoma” started in the lobules.

Other invasive types of breast cancer

• Other much less common microscopic types of breast cancer can also occur, such as medullary, tubular, scirrhous, and phylloides tumours.

Inflammatory carcinoma of the breast

• This cancer shows up as an inflammation (redness, swelling) of the skin over the tumour. This special type of breast cancer is a fast-growing (aggressive) type of adenocarcinoma. It is very rare. (1% of breast cancers in B.C.)

Paget's disease

• This cancer begins by looking like a skin disease, as dermatitis or reddening or scales on the nipple, which may be mistaken for eczema. The dermatitis is due to cancer cells invading the skin. The original tumour may not be felt on examination, and is frequently below the nipple. This is a very rare form of cancer (0.6% of breast cancers in B.C.)

Sarcomas or lymphomas of the breast

• These are very rare cancers (0.5% of breast cancers in B.C.)
  

Stages

Staging describes the extent of a cancer. The TNM classification system is used as the standard around the world. In general, a lower number in each category means a better prognosis. The stage of the cancer is used to plan the treatment. 

• T describes the site and size of the main tumour (primary);

T1 = up to 2cm in size; T2 = 2.1 to 5cm in size; T3 = bigger than 5cm; T4 = any size but tumour is fixed/attached to either the muscle under the breast, breaks through the skin of the breast, both, or there is redness/swelling of the breast) 

• N describes involvement of lymph nodes;

N0 = no underarm lymph nodes have cancer in them; N1 = 1 - 3 underarm lymph nodes have cancer in them; N2 = 4 - 9 underarm lymph nodes have cancer in them; N3 = 10 or more underarm lymph nodes have cancer in them, or other nearby lymph nodes have cancer in them. 

• M relates to whether the cancer has spread elsewhere in the body (presence or absence of distant metastases).

M0 = no cancer spread beyond the breast or lymph nodes; M1 = cancer spread 

• Stage 0 
  The tumour is non-invasive and often small. Discovered by mammography before a mass can be felt. In situ (pre/non-invasive) ductal or lobular cancer 

• Stage I 
  The tumour is less than or equal to 2 cms in diameter and there is no spread to the lymph nodes under the arm or elsewhere (T1N0) 

• Stage II 
  The tumour is larger than 2 cms but not more than 5 cms in diameter and/or involves lymph nodes under the arm. (T2N0; T1N1; T2N1) 

• Stage III 
  The tumour is larger than 5 cms or there may be a lot of involvement of lymph nodes under the arm. However, there is no spread elsewhere in the body. (T1N2; T2N2; T3N0; T3N1; T3N2; T4N0; T4N1; T4N2; T4N3) 

• Stage IV 
  The breast cancer has spread beyond the breast and area lymph nodes to another area of the body (for example bone or liver). (M1)

Treatment

Cancer therapies can be highly individualized – your treatment may differ from what is described below.

Breast cancers are treated by surgery, radiation, chemotherapy or hormonal therapy. Almost always it’s a combination of these that is offered, depending on the individual situation. The choice of treatment depends on: type, size and location of the breast cancer; age and health of patient; known or possible spread to the lymph nodes in the underarm or elsewhere in the body; tumour receptor status for estrogen, HER2 and progesterone; and patient and physician preference of treatment. 

For early breast cancer that is contained to the breast and/or underarm lymph nodes, surgery is the most important component and is usually the first treatment. 

The need for radiation, chemotherapy and/or hormone therapy is generally decided based on the information found under the microscope, after examining the removed cancer. 

For breast cancers that have already spread to distant parts of the body, surgery may not always be part of the treatment.

Surgery

Getting Ready for Breast Surgery - This booklet helps prepare patients for breast surgery at BC Cancer or Vancouver Hospital / UBC. Although most of the information is similar to breast surgery at other B.C. hospitals, please check with your surgeon or hospital for their information about getting ready for surgery. 

Surgery for invasive breast cancer includes removing the tumor from the breast and examining some of the lymph nodes from under the arm to determine if the cancer has spread. 

Surgery of the breast can be either a lumpectomy or mastectomy. 

Optimal surgery for ‘in situ’ breast cancer does not require sampling of the underarm lymph nodes, as this type of disease rarely spreads outside the breast. 

Surgery for the underarm nodes can be a ‘sentinel node biopsy’ or an ‘axillary dissection’, and sometimes both are needed. 

Lumpectomy 

This is also called Segmental or Partial Mastectomy. This surgery removes the tumour and a small margin of the surrounding normal tissue. Because of this, it saves or ‘conserves’ most of the breast. Currently, approximately 1/2 - 3/4 of all breast cancers can be treated with this breast conserving surgery.

Sometimes a surgical margin may be too close to the cancer cells, and a further surgery is recommended to remove additional tissue in this area (a “re-excision”). Occasionally a mastectomy (removal of all the breast tissue) will be recommended after a lumpectomy, if more cancer is found than was expected. 

Lumpectomy is followed by radiation therapy to the breast to reduce the chance of the cancer coming back within the remaining breast tissue. Anyone who cannot have radiation, or does not want radiation, should have a mastectomy instead. 

Mastectomy

This refers to a surgery where one whole breast is removed. There are several types of mastectomy described below. A lumpectomy is not always the safest or best surgery for breast cancer. Whether a mastectomy or lumpectomy is recommended depends on many factors, which are described in more detail below. 

• Simple Mastectomy: In this procedure, all the breast tissue is removed, but no underarm lymph nodes are removed. This type of mastectomy may be used in the treatment of in situ disease. 
  
• Modified Radical Mastectomy: In this procedure, all the breast tissue is removed, and lymph nodes under the arm are removed at the same time. 
  
• Radical Mastectomy: In this procedure, all the breast tissue and underarm lymph nodes are removed, and the muscles of the chest wall underneath the breast are removed. Although this was the standard operation for breast cancer until 1970, it is rarely performed now, as this extensive surgery has not been shown to improve survival and is more disfiguring. 
  

Reconstruction

Immediate or delayed breast reconstruction is frequently an option for patients following a mastectomy. With immediate reconstruction, a general surgeon performs the mastectomy and a plastic surgeon performs the first part of reconstruction during the same anaesthetic. Depending on what type of reconstruction is performed, further surgery may still be necessary later. With delayed reconstruction, all cosmetic reconstructive surgery is performed much later, after all cancer treatment is completed. For more information, see Breast Reconstruction and Prosthesis or Vancouver Coastal Health. 

Lymph Nodes

Lymph nodes are part of the lymphatic system, which is part of the immune system. The most common place for breast cancer to move (metastasize) to is to the lymph nodes under the arm. 

When breast cancer spreads only to the underarm lymph nodes, it is still a curable cancer. 

Because in situ cancer so rarely spreads outside the breast, underam lymph nodes are not usually removed when breast surgery is done for in situ cancer. 

During the surgery for invasive breast cancer, the surgeon usually takes out some underarm lymph nodes. A pathologist then separates out the lymph nodes from the remaining tissue and examines them under the microscope to see if there are any cancers cells inside any of them. There are two types of lymph node removal. 

• Axillary dissection: The surgeon removes all of the tissue under the arm below the axillary vein. 
• Sentinel node biopsy: Fewer lymph nodes are removed from under the arm. The breast is injected with a dye or small amount of radioactive material before surgery, and this helps the surgeon identify the underarm lymph nodes most likely to contain cancer cells. These are removed, and if no cancer is seen by the pathologist under the microscope, no further underarm lymph node surgery is required. Only about 25% of invasive breast cancers have spread to the underarm lymph nodes, so the sentinel node biopsy allows fewer nodes to be removed. However, if cancer is detected in any of the sentinel nodes, then a second surgical procedure with an axillary dissection is usually recommended. Sometimes a sentinel node procedure is not done: when the likelihood of lymph nodes containing cancer is felt to be high, or the likelihood of accurately finding the sentinel lymph node is low. 

Examining lymph nodes under the microscope provides important information about the chance (risk) of a cancer coming back, and helps guide recommendations for treatment after surgery. 
Complications of lymph node removal from the underarm. 

Complications of lymph node removal from the underarm

The risk of these complications is lower with a sentinel node biopsy than with axillary dissection, which is why the sentinel node biopsy is preferred for most patients. 

When the normal drainage of lymph fluid from the arm and breast are disturbed by a sentinel node biopsy or axillary dissection, there is a risk of lymphedema, or swelling of the hand or arm. 

Difficulty raising the arm: Following underarm surgery, scarring occurs as part of the body’s natural healing process. This can create a pulling or sore sensation under the arm when trying to raise one’s hand above one’s head. It is important to practice this kind of arm movement early and regularly after surgery to minimize this problem. 

Numbness under the arm: Surgery to the underam often results in an unavoidable injury to a nerve that provides sensation to the skin under the upper arm. This usually leads to numbness in this area, which may be permanent or very slowly improve. 

Pain in the upper arm: This occasionally happens just below where the surgery was done, and improves with time. 

Exercise after surgery is very important to return the full use and range of motion of the arm and shoulder.

Choice of surgery

The choice of lumpectomy or mastectomy, and of sentinel node biopsy or axillary dissection, depends on many factors. These include: 

• the size and location of the tumour relative to the size of the breast
  
• medical fitness of the patient
  
• the patient's own preference
  

In general, patients who are suitable for lumpectomy would have: 

• a solitary breast cancer less than 4 cm in diameter
  
• a large enough breast that removal of sufficient tissue would not leave a poor cosmetic result
  
• a preference to preserve the breast
  
• no reasons that make radiation after breast conserving surgery dangerous, impossible or impractical